LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA. 



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PRACTICAL TREATISE 



FRACTURES AND DISLOCATIONS. 



J BY 
FRANK HASTINGS HAMILTON, A.B., A.M., M.D., LL.D., 

LATE PROFESSOR OF SURGERY IN BELLEVUE HOSPITAL MEDICAL COLLEGE, AND SURGEON TO 

BELLEVUE HOSPITAL, NEW YORK; CONSULTING SURGEON TO HOSPITAL FOR RUPTURED 

AND CRIPPLED, TO ST. ELIZABETH'S HOSPITAL, ETC. ; AUTHOR OF A TREATISE 

ON MILITARY SURGERY AND HYGIENE, A TREATISE ON THE 

PRINCIPLES AND PRACTICE OF SURGERY, ETC. 



EIGHTH EDITION, 

EEVISED AND EDITED' BY 
STEPHEN SMITH, A.M.,M.D., 

PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK, AND 
SURGEON TO BELLEVUE AND ST. VINCENT'S HOSPITALS, NEW YORK. 



ILLUSTRATED WITH FIVE HUNDRED AND SEVEN WOODCUTS. 




PHILADELPHIA: 

LEA BROTHERS & CO 

18 9 1. 






\ v 









Entered according to the Act of Congress, in the year 1891, by 

LEA BEOTHEES & CO., 
in the Office of the Librarian of Congress. All rights reserved. 



I) O U N A N, PH1NTEK 



PREFACE BY THE EDITOR, 



The preparation of this edition for the press has been a grateful 
service to the Editor. He was a pupil of the Author at the time of 
the conception of the work, and during the period of the collection 
and arrangement of the greater part of the materials for the first 
edition. Subsequently he was associated with the Author, for many 
years, in the same school and hospital. These intimate relations gave 
to the Editor direct familiarity with much of the original clinical matter 
which enriches the volume. He was also personally cognizant of the 
vast amount of labor bestowed on the work by the Author in his efforts 
to perfect the several editions, and his conscientious regard for truth 
and accuracy of detail, so noticeable on every page. It is doubtful if 
any surgical work has appeared during the last half century which 
more completely filled the place for which it was designed. Its great 
merits appear most conspicuously in its clear, concise, and yet compre- 
hensive statement of principles, which renders it an admirable text-book 
for teacher and pupil, and in its wealth of clinical materials, which adapts 
it to the daily necessities of the practitioner. The efforts of the Editor 
have been in the direction of rendering the text more compact, of 
eliminating matter now irrelevant, of using a subordinate type for clin- 
ical cases, of illustrating the various subjects more fully by selected cuts, 
and of adding such new facts, cases, and opinions as were deemed neces- 
sary to render the work a correct exponent of the present state of knowl- 
edge in this department of practice. He trusts that these changes and 
additions to the last edition will prove to have, in some degree, enhanced 
the practical value and usefulness of the work. 

The new illustrations, amounting to one hundred and five, have been 
selected chiefly from such well-known works as Erichsen, Brvant, 
Stimson, Pick, Pve, etc. 

STEPHEN SMITH. 

Xf.w York. Jinuarv, 1S91. 



AUTHOR'S PREFACE TO SEVENTH AMERICAN EDITION. 



Some apology or explanation may be due to many of the writers on 
these subjects who have been occupied, especially of late, in experi- 
ments upon the cadaver, for the purpose of determining the nature, 
causes, mechanism, and treatment of fractures in the vicinity of joints, 
and of dislocations, in that the Author has not, generally, attached to 
them the same degree of importance which the experimenters seem 
to have claimed for them. 

There can be no doubt that most of these experiments furnish 
valuable information, which it would be unwise to reject ; but it is 
equally beyond doubt that the results thus obtained cannot be accepted 
as illustrating precisely what usually occurs in traumatisms inflicted 
upon the living body, while the muscles retain their normal activity. 
In the case of fractures, the rigidity of the muscles is always a factor 
of great importance in determining the seat and character of the lesion, 
and in some cases it is the sole factor. In the case of dislocations the 
same is true, only in a much greater degree. A large proportion of 
traumatic dislocations are determined in their nature, direction, and 
extent by the violent, and often spasmodic, action of the muscles acting 
in connection with the direction and force of the external violence. 
Some are dependent solely upon the action of the muscles. It is also 
the sole determining cause in all idiopathic, spontaneous, or pathological 
dislocations. In neither fractures nor dislocations made upon the 
cadaver can this action be imitated or supplemented. 

On the other hand, clinical observations alone cannot always be 
relied upon to settle a disputed point in the mechanism and nature of a 
traumatism belonging to the classes of which we are speaking, and 
especially when the question relates to a lesion involving a joint; and 
this partly because of the difficulty of making a diagnosis while the seat 



VI PREFACE TO THE SEVENTH AMERICAN EDITION. 

of lesion is covered with soft and sensitive tissues, partly because of 
the fallibility of the testimony furnished by the patients themselves, 
and partly because of the fact that the reliability of the surgeon as an 
expert who has reported the case is not always established, and the 
report has not, therefore, any more value than common " hearsay." 

Finally, nothing is more unreliable than the testimony furnished by 
cabinet specimens whose clinical history is wholly unknown ; and in 
reference to which, in many cases, it is impossible to say whether their 
present condition was due to traumatism before or after death, or, 
indeed, whether it was not due to some long preexisting pathological 
cause. The fact that by different students these specimens are often 
interpreted differently, is sufficient to justify the statement we have 
made as to their occasional worthlessness as testimony. 

From the beginning of his studies, the Author has found one of his 
most difficult labors in attempting to eliminate from the branch of 
science which he has undertaken to teach, the numerous " false facts," 
or unreliable statements derived from these several sources ; and this 
must be accepted as his apology for his repeated expressions of scep- 
ticism in reference to testimony, some of which has been accepted, as 
is believed without sufficient examination, by writers whose opinions 
might be regarded as of more value than his own. 

FRANK H. HAMILTON. 

43 W. 32d Street, New York, 
May 3 , 1 884. 



CONTENTS 



PART I. 

FRACTURES. 
CHAPTER I. 

PAGE 

General Division of Fractures 35 

CHAPTER IT. 
General Etiology of Fractures 37 

CHAPTER III. 
General Semeiology and Diagnosis of Fractures .... 41 

CHAPTER IV. 
Repair of Fractures 46 

CHAPTER V. 
General Prognosis of Fractures 51 

CHAPTER VI. 
General Treatment of Fractures oo 

CHAPTER VII. 
Delayed Union, Fibrous Union, and Non-union of Fractures . 74 

CHAPTER VIII. 

Bending, Partial Fractures, and Fissures of the Long Bones . 83 

\ 1. Bending of the Long Bones 83 

| 2. Partial Fractures of the Long Bones 86 

I 3. Fissures 93 

CHAPTER IX. 

Fractures of the Nose 96 

| 1. Fractures of the Ossa Nasi 96 

| 2. Fractures and Displacements of the Septum Narium . . . 100 



Vlll 



CONTENTS 



CHAPTER X. 
Fractures of the Malar Bone . 



CHAPTER XL 
Fractures of the Upper Maxillary Bones 



PAGE 

102 



104 



CHAPTER XII. 

Fractures of the Zygomatic Arch . . . .. . . .109 

CHAPTER XIII. 
Fractures of the Lower Jaw Ill 

CHAPTER XIV. 
Fractures of the Hyoid Bone . . 131 



CHAPTER XV. 

Fractures of the Cartilages of the Larynx 
| 1. Fractures of the Thyroid Cartilage 
$ 2. Fractures of the Thyroid and Cricoid Cartilages 
I 3. Fractures of the Cricoid Cartilage 
| 4. Fracture of the Condyle of the Occiput 

CHAPTER XVI. 



135 
138 
139 
140 
140 



2 2. 

13. 

a 4. 



2 5. 
2 6. 

2 7. 



Fractures of the Vertebrae 140 

2 1. Fractures of the Spinous Processes . . . . . . 140 

Fractures of the Transverse Process 142 

Fractures of the Vertebral Arches 143 

Fractures of the Bodies of the Vertebrae 147 

1. Fractures of the Bodies of the Lumbar Vertebrae . . 149 

2. Fractures of the Bodies of the Dorsal Vertebras . . . 151 

3. Fractures of the Bodies of the Five Lower Cervical Vertebrae 151 

4. Treatment of Fractures of the Bodies of the Vertebrae . 153 
Fractures of the Axis and Odontoid Process .... 156 

Fractures of the Atlas 159 

Fractures of the First Two Cervical Vertebrae (Atlas and Axis) at 

the same time 160 



CHAPTER XVII. 
Fractures of the Sternum .... 



CHAPTER XVIII. 

Fractures of the Ribs and their Cartilages 
§ 1. Fractures of the Ribs . 
$ 2. Fractures of the Cartilages of the Ribs 

CHAPTER XIX. 
Fractures of the Clavicle 



161 



167 
167 
171 



173 



CONTENTS. IX 
CHAPTER XX. 

PAGE 

Fractures of the Scapula 194 

| 1. Fractures of the Body of the Scapula . . . . . . 194 

I 2. Fractures of the Neck of the Scapula 198 

\ 3. Fractures of the Acromion Process 199 

I 4. Fractures of the Coracoid Process . . . . . . . 203 

CHAPTER XXI. 

Fractures of the Humerus 205 

| 1. Fractures of the Head and Anatomical Neck .... 206 

§ 2. Fractures through the Tubercles 211 

§ 3. Longitudinal Fractures of the Head and Neck, or Splitting off of 

the Greater Tubercle 212 

| 4. Fractures through the Surgical Neck (including Separations at 

the Upper Epiphysis) 213 

I 5. Fractures of the Shaft below the Surgical Neck, and above the 

Base of the Condyles 227 

| 6. Fractures at the Base of the Condyles (including Separations of 

the Lower Epiphysis) 237 

I 7. Fractures at the Base of the Condyles, complicated with Fracture 

between the Condyles, extending into the Joint . . . 244 

I 8. Fractures of the Internal Epicondyle ...... 247 

\ 9. Fracture or Diastasis of the External Epicondyle . . . 254 

\ 10. Fractures of the Internal Condyle 255 

I 11. Fractures of the External Condyle 259 

\ 12. Fractures of the Articular Processes of the Humerus (wholly 

within the Capsule) 262 

CHAPTER XXII. 

Fractures of the Radius 263 

CHAPTER XXIII. 

Fractures of the Ulna ' . . . 302 

| 1. Fractures of the Olecranon Process 302 

<§ 2. Fractures of the Coronoid Process 310 

I 3. Fractures of the Shaft 317 

§ 4. Fractures of the Styloid Process 321 

CHAPTER XXIV. 
Fractures of the Radius and Ulna .321 

CHAPTER XXV. 

Fractures of the Carpal Bones 329 

CHAPTER XXVI. 

Fractures of the Metacarpal Bones 329 



X CONTENTS. 

CHAPTER XXVII. 

PAGE 

Fractures of the Fingers 332 

CHAPTER XXVIII. 

Fractures of the Pelvis, and Traumatic Separations at its Sym- 
physes •; . . . . 335 

I 1. Fractures of the Pubes . . . 336 

{a) Separations at the Symphysis Pubis . . . . 336 

{b) True Fractures of the Pubes 337 

I 2. Fractures of the Ischium . . . . . . - . 839 

§ 3. Fractures of the Ilium . . . . . . . . .340 

1 4. Fractures of the Acetabulum . . . . . . . 343 

[a) Fractures of the Base 344 

{b) Fractures of the Rim . . . . . . . . 346 

$ 5. Fractures of the Sacrum . . . 349 

$ 6. Fractures of the Coccyx . . . . . . . . 351 

CHAPTER XXIX. 

Fractures of the Femur . . . . . . . . 352 

\ 1. Fractures of the Neck of the Femur . . . . . . 353 

(a) Neck of the Femur within the Capsule .... 354 

(b) Neck of the Femur without the Capsule . . . . 370 

(c) Neck of the Femur partly within and partly without the 

Capsule . . . . 377 

I 2. Fractures through the Trochanter Major and Base of the Neck of 

the Femur 379 

[a) Fractures through the Process .... • . 379 

(6) Fractures of the Process . . . . . . . 380 

(c) Fractures of the Epiphysis of the Trochanter Major . . 381 

I 3. Fractures of the Shaft of the Femur . . . ... 382 

| 4. Fractures at or near the Base of the Condyle .... 419 

I 5. Fractures of the Condyles . . 422 

(a) Fractures of the External Condyle . . . . '. 422 

(b) Fractures of the Internal Condyle ..... 424 

(c) Fractures between the Condyles and across the Base . . 425 

(d) Separation of the Lower Epiphysis ..... 427 
| 6. Non-union and Delayed Union of Fractures of Shaft of Femur . 428 

CHAPTER XXX. 

Fractures of the Patella . . . 429 

CHAPTER XXXI. 

Fractures of the Tibia . . . ■ . 457 

CHAPTER XXXII. 

Fractures of the Fibula 462 



CONTENTS. XI 

CHAPTER XXXIII. 

PAGE 

Fractures of the Tibia and Fibula . 470 

CHAPTER XXXIV. 
Fractures of the Tarsal Bones 491 

CHAPTER XXXV. 
Fractures of the Metatarsal Bones 496 

CHAPTER XXXVI. 
Fractures of the Phalanges of the Toes 498 

CHAPTER XXXVII. 
Gunshot Fractures 498 



PART II. 

DISLOCATIONS. 

CHAPTER I. 

General Considerations £11 

\ 1. Division and Nomenclature 511 

I 2. Predisposing Causes 512 

$ 3. Direct or Exciting Causes 513 

1 4. Symptoms . . . . ... . . . 513 

\ 5. Pathology 515 

\ 6. Prognosis 516 

I 7. Treatment . . .516 

CHAPTER IL 

Dislocations of the Lower Jaw 519 

| 1. Double or Bilateral Dislocations 519 

\ 2. Single or Unilateral Dislocations 524 

§ 3. Dislocations Outward, with Fracture 524 

\ 4. Dislocations Backward, with Fracture ...... 525 

| 5. Conditions of the Jaw Simulating Dislocation .... 526 

CHAPTER III. 

Dislocations of the Hyoid Bone 527 

CHAPTER IV. 

Dislocations of the Spine . 528 

B 1. Dislocations of the Lumbar Vertebrae 529 



Xll CONTENTS. 

PAGE 

I 2. Dislocations of the Dorsal Vertebrae 530 

§ 3. Dislocations of the Six Lower Cervical Vertebrae .... 532 

I 4. Dislocations of the Atlas 538 

\ 5. Dislocations of the Head upon the Atlas, or Occipito-atloidean 

Dislocations 540 

CHAPTER V. 

Dislocations of the Ribs . . . . . . . . .541 

§ 1. Dislocatione of the Ribs from the Vertebrae .... 541 

I 2. Dislocations of the Ribs from the Sternum 542 

\ 3. Dislocations of One Cartilage upon Another . . . . 543 

CHAPTER VI. 

Dislocations of the Clavicle . . . . . . . . 544 

\ 1. Sterno-clavicular 544 

(a) Dislocations of the Sternal End of the Clavicle Forward . 544 

(6) Dislocations of the Sternal End of the Clavicle Upward . 548 

(c) Dislocations of the Sternal End of the Clavicle Backward 550 

\ 2. Acromioclavicular . . 552 

(a) Dislocations of the Acromial End of the Clavicle Upward 552 
{b) Dislocations of the Acromial End of the Clavicle Down- 
ward 559 

(c) Dislocations of the Acromial End of the Clavicle under the 

Coracoid Process . 560 

(d) Dislocations of the Clavicle at both ends, simultaneously . 561 

CHAPTER VII. 

Dislocations of the Shoulder (Scapulo-humeral) .... 563 
§ 1. Dislocations of the Shoulder Downward (Subglenoid) . . . 564 
Dislocations, with Fracture of the Humerus near its Upper End . 592 
| 2. Dislocations of the Humerus Forward (Subcoracoid and Subcla- 
vicular) 594 

\ 3. Dislocations of the Humerus Backward (Subspinous) . . . 601 

\ 4. Dislocations of the Humerus Upward . . . . . . 606 

$ 5. Partial Dislocations of the Humerus 612 



CHAPTER VIII. 

Dislocations of the Head of the Radius (Humero-radial) 
| 1. Dislocations of the Head of the Radius Forward . 
\ 2. Dislocations of the Head of the Radius Backward 
I 3. Dislocations of the Head of the Radius Outward 
| 4. Dislocations of the Head of the Radius Downward 

CHAPTER IX. 



616 
615 
621 
624 
626 



Dislocations of the Upper End of the Ulna (Humero-ulnar) . 629 
\ 1. Dislocations of the Upper End of the Ulna Backward . . 629 

I 2. Dislocations of the Upper End of the Ulna Inward . . . 631 



CONTENTS. Xlll 
CHAPTER X. 

PAGE 

Dislocations of the Radius and Ulna (Forearm) at the Elbow- 
joint . . .631 

I 1. Dislocations of the Radius and Ulna Backward .... 631 

I 2. Dislocations of the Radius and Ulna Outward (to the Radial Side) 640 

(a) Complete Outward Dislocations 640 

(b) Incomplete Outward Dislocations 642 

\ 3. Dislocations of the Radius and Ulna Inward (to the Ulnar Side) 646 

I 4. Dislocations of the Radius and Ulna Forward .... 649 

I 5. Diverging Dislocations of the Radius and Ulna .... 651 

(a) Dislocations of the Radius Forward and Ulna Backward . 651 

(6) Transverse, Ulna Inward, and Radius Outward . . . 652 

(c) Oblique, Ulna Backward, and Radius Outward . . . 652 
[dy Oblique, Ulna Forward, and Radius Outward . . . 652 

CHAPTER XL 

Dislocations of the Wrist (Radio-carpal) . . . . . 652 

$ 1. Dislocations of the Carpal Bones Backward ..... 655 

\ 2. Dislocations of the Carpal Bones Forward 657 

CHAPTER XII. 

Dislocations of the Lower End of the Ulna (Inferior Radio- 
ulnar) 658 

I 1. Dislocations of the Lower End of the Ulna Backward . . 659 

§ 2. Dislocations of the Lower End of the Ulna Forward . . . 660 

CHAPTER XIII. 

Dislocations of the Carpal Bones (among themselves) . . .661 

CHAPTER XIV. 

Dislocations of the Metacarpal Bones (at the Carpo-metacarpal 

Articulations) 663 

I 1. Dislocations of the Metacarpal Bone of the Thumb Backward . 663 

| 2. Dislocations of the Metacarpal Bone of the Thumb Forward . 665 

§ 3. Dislocations of the Metacarpal Bone of the Fingers . . . 665 

CHAPTER XV. 

Dislocations of the First Phalanges of the Thumb and Fingers 



(Metacarpo-phalangeal) 

(a) Dislocations of the First Phalanx of the Thumb Backward 

(b) Dislocations of the First Phalanx of the Thumb Forward 

(c) Lateral Dislocation of the last Phalanx 

(d) Dislocations of the First Phalanx of the Fingers 



667 
667 
674 
675 
675 



CHAPTER XVI. 

Dislocations of the Second and Third Phalanges of the Thumb 

and Fingers (Phalangeal) 676 



XIV CONTENTS. 



CHAPTEE XVII. 

PAGE 

Dislocations of the Thigh (Coxo-femoral) 678 

§ 1. Dislocations Upward and Backward on the Dorsum Ilii . . 681 
I 2. Dislocations Upward and Backward into the Great Ischiatic Notch 706 
\ 3. Dislocations Downward and Forward into the Foramen Thy- 

roideum . 713 

| 4. Dislocations upward and Forward upon the Pubes . . . 720 
\ 5. Anomalous Dislocations, or Dislocations which do not properly 
belong to either of the four principal divisions before de- 
scribed . .726 

1. Dislocations directly Upward above the Margin of the Ace- 

tabulum, and Below the Anterior Inferior Spinous Process 726 

2. Dislocations directly Upward, between the Anterior Inferior 

and Anterior Superior Spinous Processes . . . . 729 

3. Dislocations Upward upon the Dorsum Ilii, and near its An- 

terior Margin 731 

4. Dislocations Downward and Backward upon the Posterior 

Part of the Body of the Ischium, between its Tuberosity 
and its Spine . 732 

5. Dislocations Downward and Backward into the Lesser or 

Lower Ischiatic Notch 732 

6. Dislocations directly Downward . . . . . . 733 

7. Dislocations Forward into the Perineum .... 734 

$ 6. Ancient Dislocations of the Femur . 735 

\ 7. Partial Dislocatians of the Femur . 740 

\ 8. Coxo-Femoral Dislocations, complicated with Fracture of the 

Femur 741 



9. Voluntary or Spontaneous Dislocations of the Femur . . . 743 



CHAPTER XVIII. 

Dislocations of the Patella 

$ 1. Dislocations of the Patella Outward 

\ 2. Dislocations of the Patella Inward 

| 3. Dislocations of the Patella upon its Axi 

(a) Vertical .... 

(b) Complete Version 
§ 4. Dislocations of the Patella Upward 

CHAPTER XIX. 



751 
751 

755 
755 
755 
758 
759 



Dislocations of the Head of the Tibia (Femoro-tibial) . . 760 

\ 1. Dislocations of the Head of the Tibia Backward . . . . 761 

\ 2. Dislocations of the Head of the Tibia Forward . . . 762 

§3. Dislocations of the Head of the Tibia Outward . . . . 764 

§ 4. Dislocations of the Head of the Tibia Inward .... 765 

\ 5. Dislocations of the Head of the Tibia Backward and Outward . 766 

1 6. Dislocations of the Head of the Tibia Forward and Outward . 767 

2 7. Dislocations of the Head of the Tibia Forward and Inward . 767 



CONTENTS. XV 



\ 8. Dislocations of the Head of the Tibia by Rotation . . . 768 
§ 9. Internal Derangement of the Knee-Joint 768 



CHAPTEE XX. 

Dislocations of the Lower End of the Tibia (Tibio-tarsal) 
| 1. Dislocations of the Lower End of the Tibia Inward . 
I 2. Dislocations of the Lower End of the Tibia Outward . 
| 3. Dislocations of the Lower End of the Tibia Forward . 
$ 4. Dislocations of the Lower End of the Tibia Backward 



770 
771 
775 
776 
779 



CHAPTER XXL 

Dislocations of the Upper End of the Fibula 781 

§ 1. Dislocations of the Upper End of the Fibula Forward . . 781 

\ 2. Dislocations of the Upper End of the Fibula Backward . . 782 

§ 3. Displacement of the Head of the Fibula with Fracture . . 783 

CHAPTER XXII. 

Dislocations of the Lower End of the Fibula 784 

CHAPTER XXIII. 

Tarsal Dislocations 784 

| 1. Dislocations of the Astragalus 784 

I 2. Astragalo-calcaneo-scaphoid Dislocations 794 

§ 3. Dislocations of the Calcaneum ■ \ . 795 

\ 4. Middle Tarsal Dislocations 796 

§ 5. Dislocations of the Cuboid Bone . 797 

\ 6. Dislocations of the Scaphoid Bone 797 

\ 7. Dislocations of the Cuneiform Bones 798 

CHAPTER XXIV. 

Dislocations of the Metatarsal Bones 800 

CHAPTER XXV. 

Dislocations of the Phalanges of the Toes 802 

CHAPTER XXVI. 

Compound Dislocations of the Long Bones 803 

, CHAPTER XXVII. 

Congenital Dislocations 807 

Etiology 818 

§ 1. Congenital Dislocations of the Inferior Maxilla .... 820 

§ 2. Congenital Dislocations of the Spine 823 

§ 3. Congenital Dislocations of the Pelvic Bones .... 824 

| 4. Congenital Dislocations of the Sternum 824 

§ 5. Congenital Dislocations of the Clavicle 825 

| 6. Congenital Dislocations of the Shoulder (Upper End of the Hu- 
merus) 825 



XVI 



CONTENTS 



| 7. Congenital Dislocations of the Radius and Ulna Backward 

| 8. Congenital Dislocations of the Head of the Radius 

| 9. Congenital Dislocations of the Wrist . 

\ 10. Congenital Dislocations of the Fingers 

§ 11. Congenital Dislocations of the Hip 

\ 12. Congenital Dislocations of the Patella . 

| 13. Congenital Dislocations of the Knee 

$ 14. Congenital Dislocations of the Tarsal Bones 

\ 15. Congenital Dislocations of the Toes 



PAGE 

829 
830 

830 
831 
831 
837 
838 
841 
841 



PART I 



FRACTURES 



FRACTURES. 



CHAP TEE I. 

GENERAL DIVISION OF FRACTURES. 

A Complete fracture is one in which the line of division completely 
traverses the bone. 

An Incomplete fracture is a partial separation of the bone : under 
which name are included Bending, Partial fractures, Fissures, Indented 
fractures, and Punctured 'or Perforating fractures, the last of which is 
almost peculiar to gunshot injuries. 

A Simple fracture is one in which the bone is broken at only one point. 
The term has no reference to the question of complications, but in its 
technical meaning, as employed by both English and American surgeons, 
it has reference only to the number of fragments into which the bone is 
broken. 

It would be more correct, perhaps, to substitute the word "single" for 
" simple," as has been done by Malgaigne and some other French writers, but 
I fear that to American surgeons the substitution would be rather a source of 
confusion than otherwise. 

A Comminuted fracture, called by Malgaigne " multiple," is a fracture 
in which the bone is broken at more than one point, and in which, con- 
sequently, the bone is divided into more than two fragments. It is used 
in a technical sense, and b} 7 no means implies minute division or commi- 
nution of the fragments. 

A Compound fracture is technically one in which there exists also an 
external wound communicating with the bone at the point of fracture. 
It may be either partial or complete, simple or comminuted, or even com- 
plicated, while at the same time it is also compound. 

Complicated fractures are such as present additional complications, or 
complications for which no other specific term has been invented, as, with 
the lesion of an important bloodvessel or nerve, or with great contusion 
or laceration of the soft parts, with a dislocation, or w T ith fractures of 
other bones, or even with some constitutional fault. 

A Transverse fracture exists whenever the obliquity is only moderate, 
or when, in the examination of a limb, although we are unable to detect 
the precise line of the fracture, we ascertain that, without being impacted 
or serrated, the ends of the bones continue to rest upon each other, or, 
being replaced, do not spontaneously become displaced. 



36 



GENERAL DIVISION OF FRACTURES. 



A Longitudinal fracture occurs generally in connection with an 
oblique or transverse fracture ; as when the lower end of the femur is 



Fig. 1. 





Transverse, serrated (denticulated) 
fracture. 



Oblique fracture. Called also V-shaped. 
From author's collection. 



split vertically into the joint, and the shaft of the bone is traversed hori- 
zontally by a fracture which intercepts the vertical or longitudinal frac- 
ture. 

Fig. 2. Fig. 3. 





Perforating and longitudinal fracture. 



Impacted, extracapsular fracture of neck of 
femur. Vertical section. 



GENEKAL ETIOLOGY OF FRACTURES. 37 

A fracture of a condyle, or of any projection from the body of the bone, is 
called longitudinal if the direction of the line of fracture is parallel, or nearly 
so, to the axis of the shaft. 

A Seriated or Denticulated fracture is one in which the opposite sur- 
faces denticulate, the elevations upon one fragment being reflected by 
corresponding depressions upon the other. 

Impacted fractures are those in which the fragments are driven into 
each other, the lamellated structure of one fragment penetrating the 
cancellous structure of the other. 

We speak also of fractures by avulsion, or arrachement, which are due in most 
cases to the action of the ligaments, but occasionally to the action of the 
tendons. They occur mostly in the vicinity of the joints, and consist in the 
separation of minute fragments or scales of bone, or of tubercles and tuberosi- 
ties to which ligaments or muscles are attached, and occasionally of considerable 
portions of the articular ends of bones. 

Epiphyseal separations we class with fractures, and submit them to 
the same rules of nomenclature. These accidents rarely occur after the 
twentieth year of life ; since after this period, and in the case of some 
bones, at a much earlier period, the epiphyses are usually united to the 
diaphyses by bone. 

A large proportion of these accidents seem to be due to arrachement, the 
epiphyses being torn off by the action of the ligaments or of the muscles. Sup- 
puration and necrosis are more frequent sequences than in the case of true 
fractures. 



CHAPTER II 



GENEEAL ETIOLOGY OF FRACTURES. 

Predisposing Causes. — Partial fractures, with bending of the bones, 
are. most frequent in infancy and childhood ; but complete fractures occur 
most often during manhood ; and if they are again less frequent in old 
age, it is because the exciting causes are less operative, since the fragility 
of the bones, as a general rule, increases with age. 

The influence of age as a predisposing cause of fractures consists in the 
changes which the bones undergo in advancing years by interstitial absorption, 
known as "senile atrophy.'' The interior or cancellated tissue is especially 
liable to this change ; the cavities of the cylindrical bones becoming increased 
in size and filled with fat. It will be noticed, also, that somewhat in proportion 
as the bone is more brittle, its fracture will be more nearly transverse, so that 
very old persons have occasionally what has been not inaptly termed the " pipe- 
stem fracture ; " but we must except from this rule fractures occurring in chil- 
dren, which are also sometimes transverse, often denticulated or splintered, and 
but rarely oblique. In all of the intermediate periods of life, oblique fractures 
are by far the most common. 

Females are less liable to fractures than males, except in old age, when 
the law seems, in general, to be reversed. It has been generally observed 
by surgical writers that fractures are more frequent in winter than in 



38 GENERAL ETIOLOGY OF FRACTURES. 

summer, and an explanation has been sought for in the greater rigidity 
of the muscles during the cold weather, and the greater liability to falls 
upon the ice and frozen ground. 

It is a question whether fractures are actually more frequent in the winter 
than in the summer. If, on the one hand, the rigidity of the muscles and falls 
upon slippery walks are active causes in the production of fractures in the one 
season ; on the other hand, falls from buildings and accidents from a great 
variety of similar causes are equally active agents in the other. 

Mollities ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy, 
mercurialization, and, in short, all diseases dependent upon cachexia, 
are believed more or less to predispose -to the occurrence of fractures. 

[Gurlt thinks, however, there is no evidence that scrofula or gout predisposes 
to fracture, and that syphilis is not a very frequent cause.] 

Inflammation of the periosteum also, or of the bone itself, may pre- 
dispose to fracture. It is said, moreover, that the bones of persons who 
have lain a long time in bed break easily. The liability to fracture is 
also sometimes hereditary, when there exists no recognized cachexia. 

[Goddard knew a boy who had fourteen fractures ; his mother had six frac- 
tures ; his brother had thirteen fractures.] 

We may suppose that the proportion of the earthy salts in the bones 
is increased. 

Trophic changes consequent upon disease of the nerve-centres may 
give rise to a fragility of the bones. It has been observed in lunatics, 
the paralytic, and in persons affected with locomotor ataxia. 1 

Eemarkable examples of fragility of the bones have been from time to time 
recorded. Gibson relates the case of a man who, at the age of nineteen, 
had suffered twenty-four fractures. Arnott speaks of a girl who, at the age of 
fourteen, had suffered thirty-one fractures. Esquirol had in his possession the 
skeleton of a woman in which were found traces of more than two hundred 
fractures. And we have had, at the Charity Hospital, a man aged fifty-three, 
who had suffered eleven fractures and two dislocations, in whose case the sus- 
ceptibility both to fractures and to dislocations appeared to be hereditary. 2 In 
most of these cases, so far as is known, union occurred rapidly. 

Exciting" Causes. — The exciting, determining, or immediate causes of 
fractures are of two kinds : mechanical violence and muscular action. Of 
these two, mechanical or external violence is much the more frequent 
cause ; and this violence may operate in two ways : by acting directly 
upon the bone at the point at which it separates, and then we say the 
fracture is "direct," or from "direct violence;" or by acting upon 
some point remote from the seat of fracture, and then we say the fracture 
is " indirect," or from a " counter-stroke." 

When a person falls from a height, alighting upon his feet, and the leg or 
thigh is broken, the fracture is indirect; so also if the bone is broken by flexion 
or torsion. Even direct pressure upon one side of a long bone in a child may 
produce a partial fracture upon the opposite side, which is properly an indirect 
fracture ; or a direct blow upon the trochanter major may occasion a counter- 
fracture through the neck of the femur. 

i Weir Mitchell, Amer. Journ. Med. Sci., July, 1873, p. 113. 

2 The Physician and Pharmaceutist, Feb. 1870. Report by Armenag Assadoorian. 



GENERAL ETIOLOGY OF FRACTURES. 39 

Fractures from muscular action occur most often in the patella, calca- 
neum, humerus, femur, tibia, and olecranon process of the ulna. These 
accidents may imply some condition of the bones themselves which pre- 
disposes them to fracture. 

I have seen one example of a fracture of the shaft of the femur in a large and 
perfectly healthy man, occasioned by a twist of the leg in rolling tenpins. I 
have also quite often known the tibia to break from natural muscular action in 
persons of uncommon vigor ; and there is reason to believe that the patella is 
broken more often from muscular action than from direct force. Fractures 
sometimes occur in the violent contractions of the muscles during convulsions, 
and where no abnormal condition of the bones could be assumed to exist. 
Parker, of New York, relates a case of fracture of the humerus in a negro 
preacher, which occurred in the act of gesticulation ; also, a fracture of the 
clavicle occasioned by striking a dog with a whip ; in another case the humerus 
was broken in attempting to throw a peach ; but the most singular case of all 
was a fracture of the humerus caused by an effort to extract a tooth. 1 I have 
seen the clavicle broken in the case of a man who was reaching back to lift the 
top of his carriage ; and another in which the humerus was broken in a contest 
to determine the power of the rotator muscles of the forearm. Lente has seen 
both femurs broken in epileptic convulsions, in a child twelve years of age. The 
left femur was broken at the junction of the upper with the middle third, and 
the right femur was broken at the same point eight months after, and about six 
w r eek3 later he died. The first fracture united with considerable bowing and 
shortening. The second did not unite at all. He had been subject to epilepsy 
since he was fifteen months old. 2 

Nearly all of the cases of fractures occasioned by muscular contraction 
seen by me were transverse, or nearly so, and most of those occurring in 
the long bones have been unattended with shortening, the ends of the 
bones not becoming completely displaced from each other. Intra-uterine 
fractures are not yet fully explained, but it is probable that they, like 
extra-uterine fractures, may be ascribed sometimes to external violence, 
and at other times to simple muscular contraction, both perhaps acting 
upon bones already somewhat predisposed by a peculiar constitutional 
cachexy. 

A child was brought to me having a fracture of the left clavicle, which had 
united with considerable deformity, the point of fracture being at the junction 
of the middle and outer thirds. The mother said that she fell upon her belly 
about two weeks before the birth of the child, striking upon a tub ; delivery 
occurred at the full period, in the hands of an uneducated female accoucheur. 
Four weeks later (when I was consulted) union was complete. 

Proudfoot, of New York, has related a case of compound fracture in utero, 
which was apparently caused by external violence. Mrs. F., during the sixth 
month of gestation, while attempting to pass through a very narrow passage, 
was severely pressed upon the abdomen, and immediately experienced a severe 
pain in that region, accompanied with nausea and faintness. The following- 
day, uterine hemorrhage, with pain, commenced; and these symptoms con- 
tinued at intervals, in a form more or less severe, up to the period of her 
delivery, which occurred at full time, and was perfectly natural. At birth, the 
right foot of the child, a female, was found to be much distorted, and in a con- 
dition of valgus with equinus, the outer side of the foot being laid against the 
side of the leg above the external malleolus. The tibia, also, of the same limb, 
near its middle, seemed to have been the seat of a compound fracture ; the two 
ends of the bone having united at an angle slightly salient anteriorly, and the 
skin presenting over the point of fracture an old cicatrix. 3 Dr. Eodrigue, of 

1 Parker. New York Jouru. Med., July, 1852, p. 95. 

2 Amer. Med. Times, Julv 21, 1860. p. 41. 

3 Proudfoot, New York Journ. Med., Sept. 1846, p. 199. 



40 GENERAL ETIOLOGY OF FRACTURES. 

Hollidaysburg, Pa., has communicated a case of fracture with dislocation. The 
woman, when about four months with child, fell on her left side, striking upon 
a board, and hurting herself severely. At the full period she was delivered of 
a well-grown male child. Its left humerus was found to be dislocated into the 
axilla, and both the radius and ulna of the same limb had been broken through 
their lower thirds, but were now united by bony callus at an angle of about 45°, 
and slightly overlapped. 1 Devergie has given an account of a woman who, 
when seven months with child, struck her abdomen against the corner of a 
table. Intense pain followed, lasting some time. She went her full period, and 
the child was then found to have a fracture of the left clavicle, the fragments 
being overlapped somewhat, and united in this position by a firm and large 
callus. 2 A woman also six months gone met with a similar accident, and at the 
full time she gave birth to a feeble child, having in one leg a separation of the 
shaft of the tibia from its lower epiphysis. The end of the shaft was necrosed, 
and projected through a wound in the integument. This child died on the 
thirteenth day. 3 Schubert reports the case of a female delivered before her 
term, of twins, one of whom was born with a fracture of the left thigh, which 
had occurred in utero ; the fractured bone had pierced the flesh, through which 
it projected more than an inch, and it was carious. The mother stated that 
about six weeks before the accouchement, during a movement of the foetus, she 
had heard a noise like that produced by breaking a stick, and from that moment 
she had felt pricking pains in her belly. 4 Similar cases have been recorded by 
Ploucquet, Kopp, Carus, Sachse, Moffat, and Brodhurst. 5 

In many other examples upon record 6 the explanation is plainly enough to be 
sought for in the abnormal or rhachitic condition of the bones. Monteggia saw, 
in a newly born infant, twelve united fractures. Chaussier, who has published 
a memoir upon this subject, mentions two very extraordinary cases, in one of 
which the child presented forty-three fractures, and in the other one hundred 
and twelve. 7 I saw an infant only four days old, who was born at the full time, 
of a healthy mother, in whom nearly all of the long bones were separated and 
movable at their epiphyses, the motion being generally accompanied with a dis- 
tinct crepitus. The bones were also much enlarged in their circumference ; the 
bones of the forearm and the femur were greatly curved ; the fontanelles un- 
usually open, and the clavicles were entirely wanting. The child was of full size, 
but looked feeble. It died in a condition of marasmus six months after birth, 
at which time some degree of union had taken place at several of the points of 
separation, the limbs having been supported constantly with pasteboard splints 
and rollers. 

Fractures occurring from violence inflicted upon the child by the 
accoucheur, or from contractions of the neck of the womb while the child 
is in transitu, are more common occurrences, and do not require a separate 
consideration. 

1 Rodrigue, Amer. Journ. Med. Sci., Jan. 1854, p. 272. 

2 Devergie, Rev. Med., 1825. 

3 Malgaigne, from Archiv. Gen. de Med., t. xvi. p. 288. 

4 Amer. Journ. Med. Sci., May, 1828, p. 223; from Zeitsch. fiir Staatsarz. von Henke, 
7e Erg. Heft., p. 311. Holmes's Surgery, vol. iv. p. 826. 

5 Holmes's Surgery, vol. iv. 827, from Med.-Chir. Trans., vol. xliii., 1860. 

6 Lond. Med. Times and Gaz., April 7, 1860. New Orleans Med. Journ., Nov. 1860. 

7 Chaussier, Bullet, de la Faculte de Med. de Paris, 1813, p. 301. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 41 



CHAPTER III. 

GENERAL SEMEIOLOGY AND DIAGNOSIS. 

Fractures are liable to be confounded with contusions, and with 
various other local injuries, but most often with dislocations, and espe- 
cially when the fracture has taken place near one of the articulations is 
the differential diagnosis sometimes rendered exceedingly difficult. The 
most important general or common signs of fracture are crepitus, mobility, 
and an inability on the part of the fragments to maintain their positions 
when reduced. 

Dislocations are almost as uniformly characterized by the absence of crepitus, 
by preternatural immobility, and by the fact that, when reduced, the bones do 
not usually require support to retain them in place, or indeed, we may say, by 
the fact that they are generally reducible. 

Crepitus, occasioned by the chafing of the broken surfaces upon each 
other, when actually present, is almost positive evidence of the existence 
of a fracture. It is possible, however, to confound the chafing of en- 
gorged tendinous sheaths, or of inflamed joints upon which fibrinous 
effusions have occurred, or of emphysema even, for the true crepitus of 
a fracture ; but to the experienced ear and well-practised touch these sen- 
sations are seldom a source of error The one is rough, crackling, even 
clicking sometimes ; while the other is more subdued, and imparts a more 
uniform sensation to the hand, and but rarely conveys an actual sound, 
unless the ear is directly applied or the stethoscope is employed. It is 
only when the crepitus is transmitted obscurely through a great mass of 
soft tissues, or sufficient time has elapsed for the ends of the fragments 
to become softened by inflammation and partially covered with a plastic 
material, or when, indeed, a dislocation is actually coincident with the 
fracture, that the surgeon is left in doubt. Occasionally, also, the exist- 
ence of caries or of necrosis, in connection with a dislocation, might lead 
to the supposition of a fracture ; but the history of the case, aside from 
the remaining common signs, and the special symptoms hereafter to be 
enumerated, would prevent any possibility of error. In a few cases the 
diagnosis may be facilitated by the application of the ear or of the 
stethoscope. A fracture at one point may transmit the sensation of 
crepitus distinctly enough, but in such a direction, owing to the relations 
of other bones to the one broken, as to mislead the surgeon, and induce 
him to locate the fracture in the wrong bone. 

Valuable and important as is crepitus in its relations to differential 
diagnosis, unfortunately it is not always present, and for reasons which 
must be plainly stated. First. We cannot, in a pretty large proportion 
of cases, bring the broken ends again into apposition. Whatever mere 
theorists may say to the contrary, and notwithstanding surgeons up to 
this time have rarely ventured to allude to this subject, the fact is that 
we do not usually "set" broken bones. We do not, even at the first, 



42 GENERAL SEMEIOLOGY AND DIAGNOSIS* 

bring them into complete apposition, unless it is as the exception. I 
speak of the bones once completely displaced by overlapping, and these 
constitute the majority of examples which come under the surgeon's 
observation. Second. In transverse fractures of the patella, and in 
fractures of the olecranon process of the ulna, of the acromion process 
of the scapula, and in all similar detachments of processes and apophyses, 
the action of the muscles, by displacing the fragments, may prevent 
crepitus from being readily produced. Third. In a few cases, such as 
certain fractures of the neck of the femur, of the neck and head of the 
humerus, in a Colles fracture, etc., the broken ends may be impacted, or 
so driven into each other as to forbid the production of motion and 
crepitus ; or they may be simply denticulated, and the consequences, so 
far as crepitus is concerned, will be the same. 

Finally, in very many incomplete fractures, crepitus does not exist; 
and even when it is present, the sensation is feeble, or very much modi- 
fied, sometimes giving only a faint and single click. Under the head of 
crepitus we may properly include the sharp crack sometimes felt, or even 
heard, by the patient at the moment of fracture. 

Preternatural mobility, less valuable as a means of diagnosis than 
crepitus, is, nevertheless, more constantly present, being never absent, 
in some degree, in all complete, non-impacted, and non-denticulated 
fractures ; but its presence does not, like crepitus, render the existence 
of a fracture quite certain. Whenever the bony lesion takes place in the 
vicinity of a joint, it may be difficult or impossible to determine whether 
the mobility of the limb is due to motion in the joint or to motion at the 
supposed seat of fracture ; while, on the other hand, the preternatural 
immobility so generally observed in dislocations may give place to pre- 
ternatural mobility, as when the ligaments and tendons surrounding the 
joint are extensively torn, or the system itself is laboring under the 
shock of the accident, or when from any other cause there exists great 
general prostration. 

Broken bones do not generally support themselves, but demand for 
this purpose, in most cases, the interposition of splints, bandages, and 
even of extending and counter-extending forces. This fact rests upon 
the same evidence as does the assertion already made, that bones once 
separated entirely, cannot generally be "set" — that is, placed again end 
to end in such a manner as to be made effectually to support each other. 
If we find it possible to bring the broken surfaces sufficiently into contact 
to develop crepitus, they may still be unable to maintain themselves in 
this position, owing to the obliquity of the line of fracture. 

The other common signs of fracture may be briefly stated. Pain at the seat of 
fracture; swelling ; ecchymosis ; and deformity, produced by either an angular, 
transverse, or rotary displacement of the fragments, and which is quite as often 
due to the direction and ibrce of the impulse which occasioned the fracture as 
to the action of the muscles ; separation of the fragments, as in fractures of the 
patella and olecranon process; and inability to move the limb, a phenomenon 
due in part to the breaking of the bony lever upon which the muscles acted, and 
in part to the intense pain caused by any such attempts. This latter symptom 
is, however, often entirely absent. It is not generally present in impacted 
fractures, in serrated and partial fractures, or in many other fractures in which 
the periosteum has not yet completely given way. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 43 

The cause of this fracture exercises an important influence. Fractures 
of long bones, caused by muscular action, generally occur near the 
middle of the shaft, and they are usually transverse. Direct fractures 
are also more nearly transverse than indirect fractures, but less so than 
those caused by muscular action ; while those indirect fractures which 
are caused by a force applied in the direction of the axis of the bone 
are, in general, very oblique. But what is of more importance in con- 
nection with diagnosis is, that in this latter class of cases the fracture 
usually takes place near the point upon which the force of the blow is 
received. 

Thus, a fall upon the hand generally causes a fracture of the lower end of the 
radius — a Colles fracture — or if both bones break, it is generally below the 
middle, and very seldom indeed in the upper third. A fracture of the shaft of 
the humerus near the condyles is a frequent result of a fall upon the elbow. 
The classical fracture of the clavicle, at the junction of the middle and outer 
thirds, is usually caused by a fall upon the shoulder. A fall upon the foot 
causes a fracture, in most cases, near the lower end of the tibia, and the same is 
true, quite often, of the lower end of the femur. Exceptions to the rule above 
stated are most commonly met with in advanced life, when falls upon the elbow 
occasion fractures at the surgical neck of the humerus, and falls upon the 
shoulder sometimes cause fractures near the sternal end of the clavicle. Similar 
accidents, in old people, also sometimes break the tibia near its upper extremity, 
and the femur within its capsule. 

Care and gentleness, as well as skill, in the examination of broken 
limbs, are of the greatest importance in diagnosis. Nothing, in my 
opinion, betrays a lack of judgment as well as of common humanity on 
the part of the surgeon, so much as a rude and reckless handling of a 
limb already pricked and goaded into spasms by the sharp points of a 
broken bone. It is not enough to say that such rough manipulation is 
generally unnecessary, it is positively mischievous ; provoking the muscles 
to more violent contractions, increasing the displacement which already 
exists, and sometimes producing a complete separation of the impacted, 
denticulated, transverse, or partial fractures, which can never afterward 
be wholly remedied ; augmenting the pain and inflammation, and not 
unfrequently, I have no doubt, determining the occurrence of suppura- 
tion, gangrene, and death. 

In proceeding to establish the diagnosis in any case, the surgeon 
should sit down quietly and patiently by. the sufferer, so as to inspire in 
him from the first a confidence that he is not to be hurt, at least unneces- 
sarily. He ought then to inquire of him minutely as to all the circum- 
stances immediately relating to the accident, in order that he may deter- 
mine as nearly as possible its cause, which alone, to the experienced 
surgeon, often affords presumptive, if not conclusive, evidence as to the 
nature and precise point of the injury. From this, he should proceed to 
examine the disabled limb ; removing the clothes with the utmost care 
by cutting them away rather than by pulling ; and when completely ex- 
posed, he should notice with his eye its position, its contour, the points 
of abrasion, discoloration, or of swelling ; and not until he has exhausted 
all these sources of information ought the surgeon to resort to the 
harsher means of touch and manipulation. Nor will his sensations guide 
him to the point of fracture by any other method so accurately as when. 



44 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

the patient being composed and his muscles at rest, he moves his fingers 
lightly along the surface of the limb, pressing here and there a little 
more firmly, according as a trifling indentation or elevation may lead 
him to suspect this or that to be the point of fracture. The limb, in 
case of a supposed fracture of a long bone, may now be measured with 
a tape-line, and compared with the opposite limb, having first marked 
with a soft pencil or with ink the several points from which the measure- 
ments are to be made. 

Finally, if any doubt remains, the limb must be firmly but steadily 
held while the necessary manipulations are performed, for the purpose of 
ascertaining the existence of mobility and of crepitus. Mobility is most 
easily determined by giving to the limb a lateral motion, but in general, 
crepitus is most effectually developed by gentle rotation. If the place of 
fracture is already pretty well declared by the previous examinations, 
the surgeon should place one finger over the suspected point, during this 
manipulation, by which means the crepitus will be more certainly recog- 
nized. 

Anaesthetics for the purpose of insuring quietude and annihilating 
pain in making these examinations are not often necessary. If the ex- 
amination is not satisfactory, and the diagnosis is important, do not hesi- 
tate to render the patient completely insensible, after which the questions 
in doubt may be more thoroughly investigated and perhaps definitely 
settled. Do not forget, however, that while the patient is under the 
influence of an anaesthetic, violent manipulations are no less liable to 
rupture bloodvessels, and to lacerate other tissues, than if employed when 
the patient is conscious. 

Surgeons have not seemed always to understand this, and the result has been 
that in too many instances they have inflicted serious and irreparable injury ; 
in one instance which came under my notice, the injury thus inflicted caused 
tetanus and death. 

The period of examination is important. The earlier the examination 
is entered upon, the more readily will the diagnosis be made out ; and if, 
unfortunately, some time has already elapsed before the patient is seen 
by the surgeon, and much swelling has taken place, the examination is 
still not to be omitted ; and whatever doubts remain we must endeavor 
to remove by repeated examinations, made from day to day, until the 
subsidence of the tumefaction has brought the surfaces of the bone again 
within the reach of our observation. 

[Varieties of Displacement. — An important feature in the diagnosis is to 
determine the peculiar form of displacement of the fragments which may exist. 
Without that knowledge the surgeon may mistake the direction whichshould be 
given to the forces which he employs to secure the proper apposition of the 
extremities of the bones. Malgaigne has given a very practical classification of 
these displacements, which may be usefully studied. 

1. Transverse or lateral displacement exists when the fragments pass each other 
in the transverse diameter of the bone, whether laterally or antero-posteriorly. 
This displacement occurs in transverse or denticulate fractures. 

2. Angular displacement occurs when the bones are placed at an angle with 
each other (Figs. 4, 5, and 6). This angle may be slight or obtuse. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 45 

Fig.' 4. Fig. 5. 




Angular displacement inward. 
Fig. 6. 





Angular displacement outward. 
Fig. 7. 




Presentation of fragments. 
Fig. 8. 




Over-riding of fractui 



Longitudinal displacement. 



46 KEPAIR OF BROKEN BONES. 

3. Rotatory displacement is a change in the long axis of the fragments, as in 
fractures of the femur, when the foot falls outward and changes the axis of the 
lower fragment in its relation to the upper fragment. 

4. Overriding is the most frequent displacement, and is due -to the passage of 
one fragment over the others. It is found in oblique fractures of the shaft of 
long bones (Fig. 6). 

5. Penetration of the fragment, impaction, may occur in long or short bones. 
In the long bones the shaft usually penetrates the cancellated extremity (Fig. 7) ; 
in the short bones the injury is of a crushing nature, and the fragments are 
driven into the cancellated tissue. 

6. Longitudinal displacement is found in fractures of the patella, and occa- 
sionally in the shaft of long bones (Fig. 8). 

In addition to these forms of displacement, there are combinations caused by 
the violence which produced the fracture, or by the action of the muscles subse- 
quent to the fracture. Too careful attention cannot be given to these changed 
positions when the limb is first examined.] 



CHAPTER IV. 

KEPAIR OF BROKEN BONES. 

The reparative material, consisting originally of a plastic lymph, is 
poured out from the vessels of the Haversian canals, the medullary tissue, 
the periosteum, and more or less from all of the lacerated tissues which 
are immediately adjacent to the seat of fracture ; but probably in greatest 
abundance from the periosteum. After a period, longer or shorter, this 
lymph becomes organized, and begins to receive from the same sources 
particles of bony matter, through which the consolidation is finally 
effected. The transition from the original plastic material to bone is in 
adults almost constantly through the interposition of connective tissue, 
rarely, unless in the case of children, through a cartilaginous tissue, and 
sometimes through both consentaneously or consecutively. In a few 
fortunate examples bones unite directly or immediately, without the 
intervention of a reparative material. Finally, granulation-tissue some- 
times becomes transformed into bone, in certain cases of compound 
fractures, or of fractures in which the process of inflammation exceeds 
certain limits. 

Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel, Camper, 
and Haller, declared that " nature never accomplishes the immediate union of 
a fracture save by the formation of two successive deposits of callus;" one of 
which is derived from the periosteum, the adjacent tissues, and from the medulla ; 
while the other, derived, perhaps, from the broken extremities of the bone itself, 
is found at a later period directly interposed between these surfaces. The 
material or callus derived from the tissues outside of the bone, and which Galen 
compared to a ferrule, but which Mr. Paget calls " ensheathing," together with 
the material derived from the medulla, compared often to a plug, and by Mr. 
Paget named " interior" callus, is by Dupuytren spoken of as the " provisional " 
or temporary callus, by which the fragments are supported, and maintained in 
contact until the permanent callus is formed. This temporary splint is com- 
pleted or has arrived at the condition of bone in a spongy form, at periods 
varying from twenty to sixty days ; but it does not assume the character of 



REPAIR OF BROKEN BONES. 47 

compact bone until a period varying from fifty days to six months has elapsed ; 
after which it is gradually removed by absorption. The second process, by 
which the ends of the bone are definitely or permanently united, commences 
when the provisional callus has arrived at the stage of spongy bones, and is not 
completed usually within less than eight, ten, or twelve months, "when," says 
Dupuytren, "it acquires a solidity greater than the original bone." 

While it is certain that this eminent surgeon and most accurate observer has 
described faithfully the various phenomena which usually accompany the repair 
of bones in those animals which were the subjects of his experiments, and that 
his conclusions have a certain degree of application to the human species, it is 
equally certain that he erred in assuming that in man simple fractures always 
unite by this double process; yet, such is the power of authority, these doctrines 
were accepted from the first without hesitation or debate, and for nearly half a 
century they have occupied the minds of surgeons, to the almost complete ex- 
clusion of every other theory. Mr. Stanley was among the first to question the 
solidity of the doctrines of Dupuytren, but it remained for Mr. Paget to expose 
fully their many fallacies ; nor has Malgaigne, although not strictly a disciple 
of Paget, failed to detect certain of these errors. 

I should also do injustice to myself were I not to mention that at the very 
moment when Mr. Paget was making his observations upon the specimens in 
"the large collection of fractures in the museum of University College," I 
myself was employed in similar researches both among cabinet specimens and 
in the hospitals of this country and of Europe; and that the conclusions to 
which I had arrived were nearly identical with, although the inferences were 
far from being so complete in their detail as those to which this distinguished 
pathologist was himself brought. 1 

It may now be fairly stated that fractures may unite by either one of 
the following modes : 

1. Immediately, or in the same manner that the soft tissues sometimes 
unite, by the direct reunion of the broken surfaces, and without the 
interposition of any reparative material. This happens probably some- 
times in the spongy bones, and in the extremities or spongy portions of 
the long bones, especially when one portion of bone is driven into 
another and becomes impacted ; as, for example, in some extracapsular 
impacted fractures of the neck of the femur, in certain impacted fractures 
of the head or neck of the humerus, of the lower end of the radius, etc. 

2. By interposition of a reparative material between the broken ends ; 
as when the fragments remain in exact apposition, but immediate union 
fails. This is especially apt to occur in superficial bones, such as the 
tibia; or upon those sides of the bone w T hich are most superficial. It is 
not an unusual circumstance to find the shaft of the tibia during the 
process of union presenting no exterior callus upon its anterior and inner 
surface, whilst the posterior and outer section of its circumference is 
covered w T ith an abundant deposit. In other cases, however, of fractures 
of the shaft as w r ell as of the epiphyses, the intermediate callus secures a 
prompt union, but no ensheathing callus is ever formed. 

3 Bones broken and not separated, unite occasionally by the process 
described by Dupuytren, namely, by the formation, first, of an ensheath- 
ing callus, whilst at the same moment the cylindrical cavity becomes 
closed by a spongy plug, or its canal is merely interrupted by a compact 
septum of bone; and, second, by definitive callus deposited between the 
broken ends. It is probable that this happens generally in children, or 

1 Paper on ''Provisional Callus," by Frank H. Hamilton. Buffalo Medical Journal, 
Feb. 1853. 



48 REPAIR OF BROKEN BONES. 

during the periods of the greatest activity in the development of bones ; 
and it is a common mode of union in the ribs, which bones, during the 
whole progress of the union, are necessarily kept in motion. My cabinet 
furnishes many illustrations of ensheathing callus in ribs ; and also a 
few in fractures of the tibia and fibula. 

4. Under similar circumstances, where no displacement exists, the 
fracture may unite by ensheathing and interior callus alone, no inter- 
mediate callus ever being formed between the broken ends ; in which 
case it may .be probably said that the bone itself has never united, and 
the ensheathing callus, instead of being provisional, is permanent or 
definitive. 

This was essentially the doctrine of Galen, Haller, and Duhamel before Du- 
puytren added his "fifth period,'' or the formation of definitive callus; and by 
these older surgeons it was held to be of universal application, except, perhaps, 
in the case of children. To this doctrine also Malgaigne has returned ; at least 
to the question, " Is there always a definitive callus, or complete union of the 
fragments?" he has made this laconic reply : "Galen admitted its occurrence, 
but only in young subjects ; it has been obtained in animals, where there had 
been no displacement. I would willingly believe that such is sometimes the 
case in human adults ; but I must confess I have seen only the instance above 
recited, which might just as well be used to prove the compact ossification of the 
provisional callus." He accepts, therefore, the doctrine of Galen as having not 
merely an occasional application, but as explaining the process of union in the 
large majority of cases ; and in support of this extreme view he finds that the 
exterior callus, which Dupuytren called provisional or temporary, is actually 
permanent, unless removed by the absorption consequent upon pressure. To all 
of which we can only say that an examination of five or six specimens in our 
own cabinet, after having carefully divided them with a saw, has furnished only 
one illustration of union by ensheathing and interior callus alone. In each of 
the other specimens the union was completed by definitive or intermediate callus. 
We cannot, therefore, avoid the conclusion that Malgaigne has been deceived as 
to the relative frequency of these different modes of union, and that union with- 
out intermediate callus is exceptional. 

5. When the bones are broken and overlap, they may unite by the 
interposition of a callus between the opposing surfaces- — that is, by an 
intermediate callus, but which will differ from that described as the 
second method, inasmuch as the new material will be deposited upon the 
sides of the fragments and not upon their extremities. The limb being 
kept perfectly at rest, and all other circumstances proving favorable, this 
union may take place without any excess or irregularity in the deposit. 
The surfaces will unite firmly where they are in actual contact ; and 
smooth and well-formed buttresses will fill up all the spaces between the 
bones where they are not in actual contact, sufficient generally to give 
the requisite strength to this new bond of union. This mode of union 
will be completed sometimes when the two ends of the bones are separ- 
ated laterally an inch or more from each other. 

I have in my collection the bone of a turkey's thigh (Fig. 9) thus united by a 
transverse bony shaft, although separated more than one inch; and, what is less 
common, I possess also a specimen of the adult human thigh (Fig. 10), in which 
an oblique shaft of solid callus has, after many months, and while no splints 
were employed, bound together firmly the two opposite extremities of the broken 
bone. 



REPAIR OF BROKEN BONES 



49 



6. The fragments being overlapped more or less, and suffering un- 
usual disturbance, or the adjacent tissues having been much torn, or 



Fig. 9. 



Fig. 10. 





Fracture of the humerus of a turkey; united with 
the fragments widely separated. From a specimen 
in the author's cabinet. 

much blood being effused, so that consid- 
erable inflammation is caused, the amount 
of callus will exceed what is necessary for 
the complete union of the bones ; and this 
redundancy may be deposited around and 
upon the broken ends of the bones, or 
anywhere in their immediate vicinity, in 
layers, or in masses of irregular shape 
and size. Even the bones which are not 
broken, but which are near, as in the case 
of the fibula after a fracture of the tibia, 
may become inflamed, or their coverings 
may inflame, and they may also contribute 
to the general mass of bony callus. 

Compound fractures, or rather, fractures 
accompanied with granulations and sup- 
puration, obey no uniform law of repair, 
so far as the manner and position of the 
deposit are concerned ; but they come 
together finally with more or less irregular 
distributions of ossified matter, according 
to the varying circumstances of imperfect 

coaptation, mobility, etc., in which they may chance to be placed. Occa- 
sionally the amount of callus is less than occurs in simple fractures, and 
at other times the excess is very great. 

That was, no doubt, a beautiful thought, which ascribed the formation of pro- 
visional callus to an intelligent efficient cause, which in this manner sought to 
support the fragments until a reunion of their divided ends was accomplished. 
But the beauty of a conception supplies no evidence of its truth ; and we have 
grave doubts whether Nature ever allows any interference with her laws even in 
an exigency, unless by the substitution of a miracle. Provisional callus is, in 
our opinion, just as much the necessary result of natural laws, as is definitive. 
It is formed because in that condition of the parts and of the general life its 
formation was inevitable. Whether useful for the purposes of repair or not, it 
will, under certain circumstances, exist. In the repair of certain fractures, pro- 
visional callus, it is conceded, seldom occurs. Thus it is with the cranium, the 
acromion, coracoid and olecranon processes, the patella, and with all those por- 
tions of bones which are immediately invested with a synovial capsule. Will it 

4 




Fracture of the shaft of the femur ; 
united with an oblique callus. From 
a specimen in the author's cabinet. 



50 REPAIR OF BROKEN BONES. 

be affirmed that in the examples just named this callus is not formed because it 
is not required? To us it seems that nowhere could it prove more useful, since, 
with the single exception of the cranium, it is in these very cases that the 
obstacles to a reunion are the most serious. In fractures of the patella, ole- 
cranon, etc., the action of the muscles tends constantly and powerfully to dis- 
place the fragments, and gladly would the surgeon avail himself of the assistance 
of a temporary callus, but it is rarely present, at least in any useful degree. So 
also in fractures of the neck of the femur within the capsule, and in other 
similar cases, we cannot say that temporary callus would not be advantageous 
in facilitating the retention of the fragments, yet the "intelligent efficient agent" 
neglects to furnish it. 

The only satisfactory reason which, as we think, can be assigned for the 
absence of callus in these cases, is found in the doctrines we now advocate; that 
is to say, it is usually absent because that amount of excitement and irritation is 
usually absent which alone determines its formation. In the case of the ole- 
cranon, patella, etc., the fragments being separated from each other by muscular 
action, so that no painful pinchings or charings occur, and their rough surfaces 
or sharp points being rather drawn away from than protruded into the flesh, no 
sufficient provocation exists for the production of inflammation and effusion. 
Hence the failure of provisional callus; but wherever the fracture occurs, and 
however moderate the action, definitive callus does not fail ; still the broken 
surfaces of the patella and olecranon are softened, and smoothed, and covered 
over with a new matter, which, if contact could have been secured and preserved, 
would certainly have served to consolidate and repair the breach. The natural 
reparative process proceeds, but only the accidental process is omitted. The 
latter, however, is seen again even here, when from other and unusual causes a 
sur-excitement is established. 

Temporary callus is not formed upon bones invested with synovial 
membranes, because here, too — as in the neck of the femur — -there are 
not so many structures lacerated and irritated, and the supply of this 
effusion must be the less not only in proportion to the less intensity of 
the inflammation, but also to the less amount of structures implicated. 

Possibly other and more satisfactory reasons may be assigned why provisional 
callus is not formed usually when the neck of the femur is broken within the 
capsule ; but we certainly can never admit the common, and, as here applied, 
the too palpably absurd explanation, that it is not wanted. It is wanted, and in 
no case so much as in the one now supposed. 

Provisional callus has, therefore, no final purpose, but it is the un- 
avoidable result of certain abnormal conditions. It still occurs every- 
where when against and id the vicinity of the bone there are the requi- 
site lesion and action, and it will occur as certainly when there is no 
fracture at all, but only a caries, a necrosis, or a simple bony or peri- 
osteal inflammation ; and whilst it is doubtless true that in fractures it 
sometimes renders valuable aid to the surgeon, it is equally true that it 
often proves a source of hindrance. 

Dupuytren, in determining the limits of his " third " period, or of that in 
which a provisional callus is formed of sufficient strength to support the frag- 
ments, has given what has been usually quoted as the natural period within 
which bones may be said to be united — that is, "from the twentieth or twenty- 
fifth day, to the thirtieth, fortieth, or sixtieth." But this depends so much upon 
the age of the patient, his general condition of health, the condition and position 
of the broken ends, as well as upon the bone itself, and the point at which it is 
broken, with many other circumstances, that it would be unsafe to establish any 
absolute laws in reference to this point. 



GENERAL FROGNOSIS. 51 

In very early infancy, union is accomplished in half the time required 
in adult life, and it is generally thought to be still more retarded in 
advanced age, but Malgaigne has not found this latter observation con- 
firmed by his own experience : nor have I observed any marked differ- 
ence, in this respect, between persons of middle and old age. 

Various constitutional causes retard bony union. Motion, also, some- 
times delays consolidation ; fragments which are overlapped do not unite 
as speedily as those which are placed end to end ; and other complica- 
tions interfere in a similar manner, such as lesions of nerves, of blood- 
vessels, comminution of the bone, the interposition between the ends of 
the fragments of a blood- clot, a portion of muscular, tendinous, or other 
tissue, etc. In general, the bones of the lower extremities, inde- 
pendently of their size, unite more slowly than the bones of the upper 
extremities. 

Epiphyses, when separated, unite by the same process as fractures of 
the bone. It is observed, however, that when certain epiphyses unite 
with much displacement, the shafts from which they have been separated 
cease to grow, or grow more slowly, and the limbs become atrophied. 



CHAP TEE V. 



GENERAL PROGNOSIS. 



The prognosis in fractures must vary greatly according to the place, 
character, and complications of the accident ; and for this reason it is 
impossible to give anything beyond a few general maxims at this time, 
leaving the more precise and detailed statements until we come to con- 
sider each individual fracture. 

In general it may be said that simple, oblique fractures occurring in 
the shafts of long bones unite with some shortening. Indeed, this rule 
presents but few exceptions. This is due to the overlapping or to the 
impaction, both of which we are in most cases unable completely to over- 
come. It is scarcely necessary to say that the inevitable result of such 
overlapping is a more or less manifest irregularity, or deformity at the 
seat of fracture. In general, however, the natural line of the axis of the 
limb may be preserved. Simple transverse fractures of the shafts of 
long bones, which are of rare occurrence, when completely displaced and 
made to slide past each other, are seldom effectually replaced, and are, 
like oblique fractures of the same class, apt to result in shortening and 
some deformity. 

All compound, comminuted, and complicated fractures, which in their 
very nature present additional obstacles in the way of complete adjust- 
ment and of proper support, are likely to entail deformity. Contrary, 
however, to what is generally supposed, certain compound fractures of 
the shaft of the femur, caused by thrusting a sharp fragment through the 



52 GENERAL PROGNOSIS. 

flesh and skin, if -promptly reduced, unite as speedily and with as little 
deformity as simple fractures. 

Gunshot fractures, which are necessarily in most cases compound and 
comminuted, are in a much less degree amenable to treatment with ad- 
justing and supporting apparatus than are most other fractures, and they 
necessarily entail greater deformity, both in the matter of shortening 
and lateral deviation. A certain proportion of these, as well as of other 
compound and comminuted and complicated fractures, demand, for the 
purpose of obtaining the best possible results, a course of treatment 
having in view the control of the inflammatory action as the primary 
consideration, and the relief of the deformity by lateral supports and by 
extension as the secondary consideration ; although perhaps in most 
cases both are to be regarded as necessary indications of treatment. We 
do not of course include in this statement those cases which demand 
immediate amputation. 

Simple greenstick fractures, denticulated fractures, and most trans- 
verse fractures do not become displaced in the direction of the axes of 
the bones in which they occur, and may generally be made to unite 
without shortening or deformity. They unite also very speedily. 

Fractures occurring in infancy and childhood unite more quickly than 
fractures occurring in adult life ; more speedily in the robust than in the 
feeble ; and there are certain special conditions, as we have already 
stated in the chapter on delayed union, which tend to retard bony union. 

Fractures of the upper extremities unite in general more speedily than 
fractures of the lower extremities. The smaller bones unite more rapidly 
than the larger bones. In the case of the bones of the face and jaws, 
and of the clavicle, union is especially rapid. This is probably true also 
of the ribs ; and this notwithstanding the fact that in the case of most of 
these bones we encounter peculiar and often insurmountable difficulty in 
securing absolute quiet during the treatment. 

Fractures at or near the extremities of certain long bones are less 
liable to displacement, and therefore unite with less shortening and de- 
formity than most fractures of the shaft. They unite also more quickly. 
This is true especially of fractures of the surgical neck of the humerus, 
when the fragments remain in place, of fractures of the lower end of the 
radius, of extracapsular fractures of the neck of the femur, of fractures 
of the lower end of the femur and of the upper end of the tibia. But 
some of these fractures are liable to be complicated with injuries to the 
joints, and either to endanger life or entail a partial or permanent anky- 
losis. Ankylosis is less liable to result, however, in fractures of the 
neck of the humerus, and in extracapsular fractures of the neck of the 
femur, than in fractures of the lower end of the femur, of the lower end 
of the tibia, and of the lower end of the humerus and of the radius. 

Fractures which actually involve the joints are in general much more 
dangerous to life than other fractures. This statement, however, does 
not include intracapsular fractures of the neck of the femur, and is most 
especially applicable to fractures involving the knee-joint. If old people 
pretty often die not long after receiving intracapsular fractures of the 
neck of the femur, the death is seldom due to the fracture, but rather to 
the shock received and the prolonged confinement and recumbency which 



GENERAL PROGNOSIS. 53 

are perhaps necessitated. In this last-named fracture, the union, if it 
takes place at all, is almost invariably fibrous, and the limb usually 
shortens very much. 

When the patella, or the acromion process, or the olecranon process, is broken, 
the bond of union is generally fibrous ; but if the bond is short, this does not 
materially affect the future usefulness of the limb. In the case of the patella, 
when the fracture is caused by muscular action, as it generally is, and it is a 
simple transverse fracture, the new bond of union is almost invariably fibrous. 

Ankylosis, more or less complete, is the result of nearly all fractures. 
This may be temporary or permanent. Temporary ankylosis is due, 
first, to disuse and atrophy of the muscles, and to passive contraction of 
the ligaments about the joints. Second, to inflammatory effusions and 
adhesions among the muscular fibres ; between adjacent tendons and in 
the sheaths of tendons ; in the capsules of the joints and among the 
ligaments. 

All of the forms of ankylosis above described may, but do not often, 
become permanent. Usually the products of inflammation are removed 
by the natural action of the absorbents in the course of a few months, 
and especially when the natural efforts are aided by friction, passive or 
active motion, or by other appropriate means. Passive contraction of 
ligaments and atrophy of muscles are never overcome except by motion, 
either passive or active. If they are not overcome in some degree within 
a year, they are likely to be permanent, or to require for their relief 
active surgical interference, such as brisement force, or some of the graver 
surgical operations. 

Permanent ankylosis, sometimes the result of what ought to have been 
only temporary ankylosis, is more often due to the presence of cicatricial 
tissue resulting from lesions of the muscles, to actual lesions of tendons 
or of ligaments, to firm intracapsular adhesions, and finally to bony de- 
posits in or about the joints, to bony consolidation of the adjacent bones, to 
malposition of fragments, to encroachment of fragments upon the joints, 
and to hypertrophy of fragments. 

Pain, tenderness, and more or less loss of strength in the limbs, lasting 

1 CD o 

for months or years, are common as sequels of these accidents ; but 
which phenomena have in general little or no direct relation to the 
previous existence of a fracture, unless they are present as the natural 
results of the deformity which remains. They are quite as likely to be 
entailed upon severe injuries where no fracture has occurred. 

After the removal of the splints and bandages the limb is apt to 
become cedematous; a condition which in old and feeble persons may 
continue many months, and the existence of which has been lately 
ascribed to the temporary obliteration of the deeper veins in the region 
of the fracture. This will no doubt furnish a sufficient explanation in a 
certain proportion of cases, and perhaps a partial explanation in all 
cases ; but the partial paralysis or loss of tone in the superficial veins, 
and in all the superficial tissues, due to the long-continued pressure of the 
bandages, is probably quite as responsible for these results as the deeper 
seated changes due to the injuries arising directly from the fracture. It 
is generally found to exist in a pretty exact ratio with the long continu- 
ance and tightness of the bandages. 



54 GENERAL PROGNOSIS. 

A certain amount of asymmetry in all the long bones of the extremi- 
ties is the rule and not the exception. 

The observations which led to these conclusions, were first made upon the 
lower extremities by Dr. W. C. Cox, of Philadelphia, while he was a student of 
the Pennsylvania Hospital. They were subsequently confirmed, and the exami- 
nation then extended to the upper extremities, by Dr. Wm. Hunt, of Philadel- 
phia, by Prof. J. S. Wight, of Brooklyn, by myself and others, Prof. Wight 
having especially studied the whole subject. 1 In 1879, Dr. JV Garson, 2 of 
London, published the results of the measurement of seventy skeletons, and in 
a later reference to these observations he says : u The lower limbs were equal in 
length in only seven instances, or in 10 per cent ; in twenty-five instances, or 
35.8 per cent., the right limb was longer than the left, while in thirty-eight 
instances, or 54.3 per cent., the left limb was longer than the right. The left leg 
I found not only to be more frequently longer than the right, but the difference 
in length between the two limbs is greater on an average when the left is the 
longer. Inequality in length is not confined to any particular age, sex, or race, 
but seems to be universal in all respects. My observations corroborated those 
of several American surgeons made on the living subject." Measurements of 
fifty skeletons showed a like asymmetry in all the long bones, but in the case of 
the arms the right is more often the longer. The conclusions reached by all 
have been nearly identical, namely, that throughout the long bones of both 
extremities there existed usually a certain amount of asymmetry in regard to 
length. Ordinarily the difference is inconsiderable, ranging from one-eighth of 
an inch to one-half, but sometimes much exceeding this without having been 
noticed by the patient or by his friends. In the case of the lower extremities 
the left is more often longer than the right. 

These conclusions by no means render the measurements of limbs 
valueless, although they place a serious obstacle in the way of our attain- 
ing that precision which is desirable when we seek to determine the 
relative value of different plans of treatment in preventing shortening. 
Unfortunately, I may say, we have not yet devised a method of exten- 
sion so effective that our ignorance of the original normal differences 
causes any embarrassment. The fact is, and always has been, that 
measurement of the limb in which a long adult bone has been broken 
obliquely and has united, shows, in a large majority of cases, that it is 
shorter than the other ; and the frequency of this occurrence is evidence 
that in many cases it becomes the shorter limb, although it was origi- 
nally the longer, and it leaves a possible question whether those few cases 
which we have regarded as perfect results, because the opposite limbs 
were after consolidation of the same length, were not then symmetrical 
solely in consequence of the shortening ; and we may consider it probable 
that in other cases the actual shortening is much more than is indi- 
cated by the measurements. Nevertheless the unpleasant fact remains, 
and is rendered only the more conspicuous, that oblique fractures of the 
long bones in the adult generally shorten, inasmuch as we find in 
nearly all cases the broken limb the shorter. When we have found 
an apparatus or a mode of dressing which will make a broken limb as 
long as or longer than the other as often as it is found to be normally, 
then we may lay aside the tape and line, for it will be of no further use ; 
practically, also, our labors will be ended, for shortenings no greater 

1 Philadelphia Medical Times. Jan. 16, 1875. Amer. Journ. Med. Sci., April, 1875. 
Archives of Clinical Surgery, Feb. 1877. Hospital Gazette, April 12, 1*79. 

2 Garson, Journal of Anatomy and Physiology, vol. xiii. p. 502, 1879. Nature, Jan. 26, 1884. 



GENERAL TREATMENT OF FRACTURES. 55 

than normal deviations occasion no maiming or halting, and are of no 
consequence. 

I think it proper to mention venous and fatty embolisms in connection 
with prognosis in fractures, since modern pathological investigations have 
established their occasional connection as sequences, if not as conse- 
quences. 

Virchow, in 1846, was the first to call attention to an example of pulmonary 
embolism due to the presence of a venous clot and consequent upon a fracture. 
Since then, similar examples have been reported by other surgeons ; the acci- 
dents having taken place usually at periods varying from two to six or seven 
weeks after the fracture occurred, and being due, as is believed, to the displace- 
ment of a clot from a vein in the vicinity of the fracture, whose channel had 
been temporarily closed by inflammation and pressure. 

The presence of a pulmonary venous embolism in the lungs may be recognized 
by the sudden occurrence of pain, cough, and dyspnoea, accompanied, perhaps, 
with bloody expectoration, and the usual physical signs of localized congestion 
or consolidation. In some cases, the symptoms are more urgent, and the patient 
dies in a few minutes. 

In 1864, Flournoy reported a death from fatty embolism, consequent 
upon a fracture of the leg, death having occurred thirty-six hours after. 
Since then, Busch, Wagner, Czerny, and others have reported similar 
examples. The accident is supposed to be due to the absorption into the 
venous and capillary circulation of the crushed fat globules contained in 
the marrow at or near the point of fracture. The symptoms are said to 
resemble those of shock and of traumatic and alcoholic delirium ; but an 
interval always exists between the occurrence of the accident and the 
accession of the symptomatic phenomena, which latter are by no means 
uniform, the most reliable signs being referable to pulmonary and cardiac 
obstructions. The breathing becomes suddenly difficult or labored ; the 
pulse becomes feeble and rapid, the countenance pale or cyanosed, and 
delirium, followed by coma, terminates speedily in death. It is affirmed 
also, that in other cases, where the fatty embolisms are less extensively 
distributed, the symptoms, although presenting the same general type, 
are less urgent, and may terminate in recovery. 

It is gratifying to know that both of these forms of embolism, as sequences of 
a fracture, are probably exceedingly rare, and that some excellent pathologists 
have even denied that any relation whatever has been shown to exist between 
the presence of the oil-cells in the bloodvessels and capillaries and the symptoms 
which have been attributed to them. 



CHAPTER VI. 

GENERAL TREATMENT OF FRACTURES. 

All that has been said in relation to the propriety of handling a 
broken limb gently, when the surgeon is examining the position and 
character of the fracture, is equally applicable to the lifting and trans- 
porting of the patient to his bed/ to the removal of the clothing, and 
to the general management of the limb before it is dressed. Rude or 



56 GENERAL TREATMENT OF FRACTURES. 

awkward manipulations, by which needless pain is inflicted, are not 
simply acts of wanton cruelty, but they are sources, and I think I may 
say frequent sources, of inflammation, suppuration, and gangrene. Here, 
as in all the subsequent handlings, everything should be done slowly, 
thoroughly, and systematically. Yet it is difficult to state the precise 
manner in which the surgeon ought to proceed. Much will depend upon 
the circumstances of the case, something upon one's natural tact, and 
upon the amount of experience, but more, I think, upon natural kind- 
ness of heart and social education. The man of refinement and sensi- 
bility will know instinctively how to proceed, and needs no instruction. 
They who lack these qualities can never learn, and it would be quite 
useless to undertake to teach them. 

[§ 1. The Immediate Care and Dressing 1 of Fractures. 

While it is desirable to reduce a fracture at the earliest possible moment after 
the accident and retain the bones in apposition by retentive dressings, it rarely 
happens that this can be effected at once without an amount of pain and incon- 
venience that is very disturbing to the patient, and may prove injurious to the 
parts involved in the injury. There is, therefore, a period in the history of 
nearly every fracture when temporary dressings are required. This is especially 
true of fractures that occur when the patient is absent from home, and he must 
be immediately subjected to transportation, It is with reference to this latter 
class that the following remarks are principally made. It may be stated that, as 
a rule, fractures occur under circumstances which necessitate the removal of the 
patient to his home. In this removal the limb, or part injured, is liable to be 
subjected to such rude handling that the local injuries are greatly aggravated, 
and the discomfort and sufferings of the patient are immensely increased. 
Fractures that would be attended with little pain and very moderate swelling, 
if properly treated where the accident occurred, may, by the first manipulations 
of the surgeon in preparing the patient for removal, or by the rough handling 
of inexperienced persons in his transportation, be rendered serious, or even be 
changed from a simple to a compound fracture. It is of the utmost importance, 
therefore, that from the occurrence of the fracture to the final removal of all 
dressings, intelligent care and adequate skill should be exercised. 

Removal of the clothes of a patient who is to be transported some distance 
is usually unnecessary, and should be delayed until he is placed on his bed. The 
exceptions to this rule are cases of compound fracture with hemorrhage, and 
crushed fractures, which require special care and dressing. Splints can be 
applied to the part outside of the clothes in such manner as to steady the frac- 
tured bone, and prevent the fragments from further lacerating the parts. It is 
not necessary to reduce the displacement except so far as to make the patient 
comfortable. These dressings must not be too tight. Arrived at the bed the 
patient should be placed upon it in a comfortable position, and the clothes re- 
moved, chiefly by cutting them away. While they are being removed an assist- 
ant may be able so to support the part as to prevent all movement of the frag- 
ments. 

The Materials. — The materials for these temporary dressings must be such 
appliances at hand as will prevent further injury to the parts while the patient 
is being removed to his home and bed. Thin pieces of board or sides of cigar 
boxes, with pads of cotton wadding or folds of cloth next to the limb make very 
serviceable splints for the arms and legs. Pasteboard and book covers may be 
of service, especially for the arms and elbows. Towels or sheets may be used 
for slings or bandages, and even a well-folded newspaper may sustain the parts 
sufficiently. An umbrella, a cane, a broom handle, a crotched stick are a few 
of the common materials which have served a good purpose in cases of great 
emergency. Success in the selection and employment of such materials for 
dressings will depend much upon the skill and ingenuity of the surgeon. 
(Fig. 12.) 



CARE AND DRESSING OF FRACTURES. 



57 



Fractures of the Spine.— The immediate care of a person suffering from a 
fracture of the spine must be most judicious. A slight force improperly applied 
may result in such displacements of the fragments as will result in paralysis, or 
even in death. The danger of doing great harm to the patient by moving him 
is greater when the fracture is in the cervical region, and is greatest when it is 
in the upper part of this region. The movements which are more likely to dis- 
place the bones are those of rotation or flexion of the spine. The position which 



Fig. 11. 



Fig. 12. 




Treatment of fractures of clav- 
icle with two towels, or triangu- 
lar bandage. (Pye.) 



Improvised splintiug. (Pye.) 



most directly relieves local pressure is the recumbent, on a smooth, firm surface. 
And the force applied to the spine which is least liable to cause injury is gentle 
traction. From these facts it is apparent that the patient should at once be 
placed in a recumbent position on a smooth surface, as a stretcher, a board, a 
shutter, or similar support for transportation. In raising the patient from his 
position to the stretcher no movement should be made which bends or rotates 
the spine, and slight traction of the trunk should be constantly maintained 
during the change of position. In transportation the patient should not be sub- 
jected to any jarring or jolting, as in a common wagon on a rough road. When 
the patient reaches his destination he should be removed to his bed with the 
same care and the same attention to minute details. Finally, the removal of 
his clothes must be effected without any disturbance of the spine. In general 
those fitting tightly, as shirts, should be cut with shears. 

Fracture of the Ribs. — These fractures are attended with acute lancinating 
pains in the chest wall, which recur on, and are greatly aggravated by, forced 
respirations, coughing, or jarring of the body. The patient involuntarily pro- 
tects himself by short respirations, avoiding coughing and jarring, and by pres- 
sure over the injured ribs to prevent the movements of the fragments. Persons 
suffering from fractured ribs can usually be removed without material injury. 
They can walk cautiously without great inconvenience and by pressure of tlie 
hand or arm upon the side can relieve in a great measure their sufferings. The 
best dressing is a firm bandage, four to six inches in width, as a towel, pinned 
tightly about the entire chest. 

Fractures of the Pelvis. — These fractures are more difficult of diagnosis, 
and can only be conjectured on first examination. They may be inferred from 
the nature of the injury, as the passage of a heavy wheel over the pelvis, Xoth- 
ing can be recommended that will prove more serviceable in the first care of 
such a patient than has been given in connection with fractures of the spine. 

Fractured Lower Jaw. — The first treatment of this fracture should be to 
support the jaw in contact with the other by a bandage around the chin and 



58 GENERAL TREATMENT OF FRACTURES. 

over the head. The patient should not be allowed to talk nor to take solid food. 
As a temporary dressing until the final apparatus is applied cardboard may be 
shaped so as to make a complete splint for the jaw and chin by moulding it 
when softened in water, the splint being retained by a split bandage; the 
centre being applied to the chin, the two lower tails being tied over the vertex, 
and two upper behind the head. 

Fractured Clavicle.— The displacement in this fracture is most readily and 
completely overcome by placing the patient on a firm bed on his back with a 
pillow between his shoulders. This position is also most comfortable to the 
patient. If, however, he is to be removed some distance the arm should be so 
fixed in a sling that the shoulder of the injured side will be elevated and carried 
slightly backward. This is effected by bringing the elbow forward, placing a 
pad in the axilla, and then applying a sling which includes the elbow. Pye 
gives the following method : " A soft, but firm pad, of about the size of one's 
fist is made, as with a cricketing cap or a newspaper, and is placed in the axilla; 
the forearm is crossed over the chest with the hand pointing to the opposite 
shoulder, the point of the elbow being held well back. A towel is then folded 
as a broad scarf, the elbow is settled into the middle of it, and then, by tying 
the ends over the opposite shoulder, the hand and forearm being covered by the 
scarf, the arm on the injured side can be pushed well up. The other towel is 
then brought round so as to fasten the arm, forearm and hand firmly to the 
trunk and the ends are knotted or pinned beneath the opposite armpit." (Fig. 9.) 

Fractures of the Humerus. — If the fracture is near the shoulder there will 
be slight tendency to displacement, and no other dressing is required than such 
support of the arm as may be given by a sling which includes the entire forearm, 
elbow, wrist and hand. If moderately tightened about the neck this sling will 
support the fracture sufficiently. 

Owing to the great leverages of the arm and the hinge-like action of the 
elbow, fractures of the shaft of the humerus are readily displaced by the move- 
ments of patients. Whatever position the patient may take, whether recum- 
bent, sitting, or walking, the proper apposition of the fragments will not be 
retained without the careful application of splints. It is important, first, that 
the forearm be flexed and fixed to the body. By this means the action of 
the elbow is very completely controlled. Without removing the clothes a pad 
should be prepared, which may consist of several folds of cloth, and placed 
along the inside of the arm, from the axilla to the elbow, as a support to the 
shaft. The arm being then placed upon the chest, with the fingers pointing to 
the opposite shoulder, a bandage should be passed around the body and across 
the elbow, fixing the elbow in this position. A sling, consisting of a handker- 
chief or strip of cloth around the wrist, is used to support the hand. If the 
elbow is not thus supported against the body four short splints of light wood or 
cardboard, padded, should be applied to the arm and fixed by tapes, while the 
hand is supported in a sling about the wrist. 

Fractures Near and at the Elbows.— The mobility of the elbow-joint 
must be fixed, and the position must be flexion at right angles. Common card- 
board or thin sole leather, shaped to the bend of the elbow, is a convenient and 
admirable dressing. The splint should extend from the middle of the forearm to 
the middle of the arm and be made much larger than the elbow. It should now 
be placed in hot water, and when soft and yielding moulded to the parts. It 
should next be well protected by cotton wadding, the cotton being in excess 
about the prominent parts of the joint. The splint is best retained by a band- 
age extending its entire length. The hand should be supported by a sling around 
the wrist. 

Fractures of the Forearm. — Fractures occurring at any point of the fore- 
arm are best supported by two broad splints applied, one to the anterior and the 
other to the posterior surface. They should extend from the elbow to the hand, 
the anterior reaching to the middle of the hand to prevent pronation. The 
sides of cigar boxes answer a good purpose. They should be wider than the 
arm and well padded. When applied the forearm should be held bo as to make 
the bones parallel, the thumb being upward. The splints may be held in place 
by tapes, care being taken not to make them too tight. The forearm should be 
supported by a sling. 



GENERAL TREATMENT OF FRACTURES. 59 

Fracture of the Neck of the Femur. — The most important fact to be borne 
in mind in the care of this injury is this, the fracture may be partial or im- 
pacted. If it is partial or impacted it is in the best possible condition for rapid 
union. But by rude handling, as in lifting the patient, the partial or impacted 
fracture may be made complete, and thus in a moment irreparable injury is done 
to the patient. It is well to assume, in all cases, that the fracture is not com- 
plete, for if that fact is prominently in the mind of the surgeon who prepares 
his patient for transportation, he will exercise that degree of care which is 
essential in all cases. A well-padded, long splint should be applied, extending 
from the foot to the axilla, and be retained by a broad towel around the hips 
and stout bandages at other points. This dressing should be adjusted without 
removal of the clothes, and with as little movement of the limb as possible, 
except that the foot should be placed in its proper position if it is too much 
everted or inverted. 

Fracture of the Shaft of the Femur.— In this fracture there is usually 
much displacement at first. A long splint should be applied externally from 
the foot to the axilla, as in the preceding case, and a short splint internally from 
the foot to the groin. Before they are fastened to the limb, the leg should be 
gently but firmly extended and the eversion of the foot corrected. Plaster-of- 
Paris, if at hand, may be used with great advantage in the form of a splint. 
This can be made of two layers of woollen blanketing, cut of the length of the 
thigh and sufficiently wide to surround the limb. The blanket is soaked in the 
dissolved plaster and quickly applied, and retained by bandages. In a few 
minutes it will be firm. This dressing is to be preferred if the patient is to be 
transported a long distance. 

Fractures Near or Into the Knee-joint.— The same dressings as in frac- 
tures of the shaft of the femur are generally best adapted to secure the limb 
from further injury when the fracture is near or into the joint. It may happen 
that the slightly flexed position is most comfortable. In that case the knee may 
be bent over a firm pillow or other support. 

Fractures of the Patella. — The important point to be made in this fracture 
is that the leg must not be flexed, but rather must be maintained in a state of 
extreme extension. For this purpose a firm splint must be applied on the pos- 
terior part of the limb, extending from the middle of the thigh to the middle of 
the leg, and be firmly retained by a bandage or broad tapes. 

Fractures of the Leg. — The plaster-of-Paris splint above described makes 
the best dressing for these cases and is most readily applied. The blanket must 
be cut in such manner as to form a good covering of the foot. Another dress- 
ing, which may be readily extemporized, is a thin pillow, of hair, straw, or even 
feathers. The leg is placed in the middle and the sides of the pillows are folded 
up over it ; then several tapes are firmly tied at different points around the 
whole. The same dressings are most useful when the fracture involves the parts 
entering into the ankle-joint.] 

§ 2. General Treatment of Fractures. 

Nearly all fractures present three principal indications of treatment, 
namely : to restore the fragments to place as completely as possible ; to 
maintain them in place ; and to prevent or to control inflammation, 
spasms, and other accidents. It ought to be regarded as a rule, liable 
only to rare exceptions, that broken bones should be restored to place, or 
to the position in which we hope to maintain them, as soon as possible 
after the occurrence of the accident. If the patient is seen within the 
first few hours, or before much swelling has taken place, we scarcely 
know the circumstances which would warrant an omission to adjust the 
fragments either end to end or side by side, as the one or the other might 
be found to be practicable. 

We have before sufficiently explained the general impossibility of again 
restoring to place, end to end, and fibre to fibre, fragments which have been 



60 



GENERAL TREATMENT OF FRACTURES. 



made to override. We are therefore in no danger of being understood to say- 
that bones should in all cases be immediately " set," in the popular sense of this 
term. They ought to be '' set," no doubt, if this can be accomplished through 
the application of a prudent amount of force ; but if they cannot be thus placed 
end to end, they may at least be laid in such a manner side by side as to restore, 
in some measure, the natural axis of the limb, and prevent the points of the 
bone from pressing unnecessarily into the flesh. 

Experience has, indeed, furnished us with four or five very good reasons 
why broken bones should be reduced as soon as possible. When the 
injury is recent, the muscles offer less resistance ; their resistance being 
increased after a time not only by the reaction which ensues upon the 
shock, but also by actual adhesion between their fibres; effusions distend 
both the muscles and the skin, and compel the limb to shorten ; the 
constant goading of the flesh by the sharp points of the broken bones 
increases the muscular contractions ; the patient will submit readily to 
manipulation and extension at first, but after the lapse of a few days it 
is very seldom that he will permit the limb to be in any manner dis- 
turbed, even if he is assured that his refusal entails upon him a great 
deformity. If it is true that no callus or bony structure is deposited 
earlier than the seventh or tenth day, it is also true that the renewed 
attempt to adjust the bones at this period, by chafing and tearing again 



Fig. i; 



Fig. 14. 





Many-tailed bandage. 

the tissues, reduces the fracture, 
in some degree, to the same condi- 
tion in which it was at first, and, 
consequently, the time which has 
elapsed, or, at least, a portion of 
it, may be regarded as lost. 

We cannot, therefore, understand 
the argument by which Bromfield, 
South, and a few other surgeons have 
persuaded themselves, that reduction 
should never be attempted before the 
third or fourth day ; nor, indeed, do 
we fully appreciate the refinement 
which Malgaigne has given to this 
question, in itself so simple. To affirm 
that we ought not to reduce the bones 
to their original positions during the period of intense inflammation, or of great 
swelling, or while the muscles are acting spasmodically, is only to affirm that we 



Application of the " roller " by circular and 
reversed turns. 



GENERAL TREATMENT OF FRACTURES, 



61 



may not do what is impossible; and the attempt to do which, therefore, can 
only be mischievous ; but to authorize their restoration to abetter position, by 
such manipulation, extension, and lateral support as they may comfortably bear, 
is warrantable under any circumstances. The practice is not only defensible, 
but imperative, and we do not think any really sound and practical surgeon 
ever intended to teach the contrary. We say still, if bones can be easily reduced, 
or the position of the fragments improved at any moment, or under any circum- 
stances, it ought to be done; and if we fail in accomplishing all that we wish 
to do in the first instance, we must remain incessantly watchful to seize the 
earliest opportunity which presents, to complete the adjustment. No doubt our 
efforts will prove fruitless very much in proportion to the amount of swelling, 
inflammation, or muscular spasm which exists, and also in proportion to the 
time which has elapsed ; but this will not excuse us for omitting to do all which 
the circumstances permit. 

Of the primary dressings there are two principal varieties : first, the 
" roller " or simple bandage, applied to the limb in circular and reversed 
turns ; and second, the " many-tailed bandage," consisting of a piece of 
muslin, or other cloth torn down from each side into a suitable number 
of strips, leaving the centre, which is to be applied to the back of the 
limb, entire. 



Fig. 15. 



Fig. 16. 




I •"" 





\ 


v 


I 




^11 




1 



Application of the many-tailed bandage. 



Bandage of Scultetus. 



A modification of this latter bandage consists of a number of separate strips, 
so laid upon one another, commencing from above, that each strip shall overlap 
the other by one-third or one-half of its breadth. This is called the bandage of 
Scultetus, and it possesses one advantage over the many-tailed bandage just 
described, especially in the case of compound fractures, in the facility with 
which each separate piece may be removed and another substituted. Some 
surgeons prefer to form the bandage of separate strips, and having overlaid them 



62 GENERAL TREATMENT OF FRACTURES. 

in the manner directed, to unite them again into one by running a thread 
through the whole mass along the centre. Whichever of these several varieties 
of strips are employed, the mode of applying them is the same. They are folded 
alternately around the limb, being made to overlap and cross upon each other 
in front, and only the last strip or two is fastened with a pin. 

The object proposed in the use of the roller or of the many-tailed 
bandage is two-fold ; first, to compress and support the muscles, by which 
their tendency to contraction is in some measure controlled ; and second, 
to protect the limb against the direct pressure of the side-splints. 

A moment's consideration will convince us that the first of these objects is in 
most cases fully attained by the lateral splints themselves, and by the bandages 
by which they are retained in place ; and that the second can be as well accom- 
plished by a single fold of cloth, or by the compresses, which ought generally, 
even when the roller is used, to underlie the splints. Nevertheless, we should 
hardly feel authorized to reject these primary dressings solely because the splints 
and compresses furnish a convenient substitute, especially since we are com- 
pelled to admit that they are occasionally useful, unless objections of a more 
serious nature could be brought against them. Unfortunately, this latter sup- 
position is actually true. By ligating the limb completely, leaving no point of 
the tegumentary surface to which the pressure is not applied, they too often 
occasion congestion, inflammation, and gangrene. It is not until lately that the 
attention of surgeons has been sufficiently called to this subject ; but the records 
of surgery are to-day filled with these terrible accidents, formerly attributed to 
the original injury or to the splints themselves, but now understood to be plainly 
traceable to the too common employment of the primary bandage. The roller 
is by far the more dangerous dressing of the two, since it does not yield to the 
swelling so readily as the bandage of strips, and it is more objectionable also on 
account of the inconvenience of applying and removing it ; but even the band- 
age of strips may be so confined as to produce the same consequences, as I 
myself have seen in more than one instance. It is also all the more dangerous 
in the hands of the inexperienced surgeon, because he feels a confidence that it 
will not cause ligation. 

Except in rare cases and for especial reasons, which I shall attempt to 
indicate in their appropriate places, I cannot recommend the employment 
of any kind of bandages next to the skin. 

In order to fulfil the second indication, namely, to maintain the frag- 
ments in place, we employ usually what are called short, side, or coapta- 
tion splints, and long or extending splints, or the weight and pulley. 

Side-splints may be constructed from various materials, according to the size 
and circumstances of the limb, or according to the convenience of the surgeon ; 
and as the surgeon cannot be expected to have always on hand, at the bedside 
of the patient, such splints as he might prefer to use, it is well for him to under- 
stand how to avail himself of such materials as may be within his reach, in order 
that he may make the most of his sometimes imperfect resources. 

Lead, sheet-iron, zinc, and other metals have been occasionally employed, but 
especially tin and copper, which possess all of the requisite firmness and mallea- 
bility to allow them to be hammered, and thus moulded to the limb. In general, 
however, they are unnecessarily heavy, and demand too much labor to be wrought 
into shape. I have sometimes employed tin splints perforated with large fenestras 
to diminish their weight and increase their flexibility, and found them to answer, 
in certain emergencies, an excellent purpose. The light perforated zinc splints, 
introduced into the TT. S. Army during the civil war of 1861-65, by the Sanitary 
Commission, were found exceedingly useful for field service. 

Iron-wire splints, made from wire-cloth or coarse gauze, were first publicly 
mentioned, so far as I can learn, in a communication to the Memphis Medical 
Recorder, made bv Dr. J. C. Nott, of Mobile ; but thev have been brought more 



GENERAL TREATMENT OF FRACTURES. 63 

particularly into notice, and their construction perfected, by Louis Bauer. 1 
These splints, as modified by Bauer, are moulded upon " gypsum or wooden 
casts,'' of different sizes, and surrounded with a stout iron-wire frame, in order 
to give them the requisite degree of firmness, and to preserve their forms ; after 
which they are tinned by galvanism, and varnished, to prevent them from be- 
coming rusted. When applied, Dr. Bauer recommends that they shall be filled 
with loose cotton, and that they shall be held in place by rollers. It is claimed 
for these splints that they are light, flexible, permeable to air and to the per- 
spiration, and that they permit the application of cooling lotions without im- 
pairing their firmness ; the last of which is a quality of questionable value, since 
lotions applied to permanent dressings of any kind are only warm fomentations, 
and do not, therefore, in this respect serve the purpose for which they are 
intended. They render the skin tender and disposed to vesicate, and they also 
give rise to a sensation of scalding, which is sometimes almost intolerable. The 
water soaks into the bed, and in many other ways renders the patients uncom- 
fortable. Lotions are only applicable where the dressings are open, loose, and 
temporary. 

According to Poinsot (note to French edition of this work), the wire-gauze 
splint has been used in the Hospital of St. Andrew, Bordeaux, since 1868 ; a 
strip of leather being substituted for the stout wire frame of Bauer. 

The same objections hold, also, to this as to all other forms of moulded metallic 
or carved wooded splints, namely, that they seldom exactly fit the limb, even 
when the supply of assorted sizes is complete, and that they are not sufficiently 
flexible to adapt themselves to anything but the slightest irregularity of surface. 
They are not, however, without merit, and they deserve at least a qualified com- 
mendation in many cases. 

Horn and whalebone may be employed in thin plates, or in the form of narrow 
strips quilted into cloth ; but they are expensive, and possess no special value 
except in an emergency. Reeds, the coarse rank grass which grows in swamps, 
flags, willow branches, and unbroken wheat straw, may be quilted between two 
thicknesses of cloth in the same manner, and form very excellent temporary 
splints. I have especially found it convenient to use wheat straw in the form of 
junks. Gathering up a bundle of unbroken straws of the size of my arm, I roll 
them snugly in a broad piece of cotton cloth, cut off the projecting ends, and 
then stitch up the cloth neatly. We have thus a splint of considerable firmness, 
and one which is cool and especially adapted to the summer, allowing the per- 
spiration to evaporate freely. Straw splints were employed sometimes by 
Ambroise Pare, by J. L. Petit, Larrey, and I have seen them in the wards of 
certain European hospitals, although I am unable now to say under whose direc- 
tion. Mr. Tuffnell, of Dublin, has especially recommended them in the form of 
junks. 2 

Wooden splints, made of pine, willow, white or linden wood, or of some other 
light and easily wrought timber, are probably of more general application, and 
possess greater intrinsic value than aplints constructed from any other solid 
material ; but I wish at once, and for all, to disclaim any intention of giving 
even a qualified approval of any of those carved, polished, and generally patented 
wooden splints, which are manufactured and sold by clever mechanics, and 
which one may see suspended in almost every doctor's office, whether in the 
city or in the country. Constructed with grooves and ridges, and variously 
inclined planes, for the avowed purpose of meeting a multitude of indications, 
such as to protect a condyle, to press between parallel bones, to follow the sub- 
sidence of a muscular swelling, etc., they never meet exactly a single one of these 
indications, whilst they seldom fail to defeat some other indication of equal im- 
portance. They deceive especially the inexperienced surgeon into the belief 
that he has in the splint itself a provision for all these wants, and consequently 
lead him to neglect those useful precautions which he would otherwise have 
adopted. 

If carved wooden splints are employed, they ought to be made especially for 
the case under treatment. But this requires time and some more mechanical 

1 Nott and Bauer, Buffalo Med. Journ., vol. xii., April, 1857. 

2 Tuffnell, New York Journ. Med., March, 1847, p. 264. 



64 



GENERAL TREATMENT OF FRACTURES. 



skill than can always be commanded ; and when accurately fitted, it is quite 
probable that the subsidence or increase of the swelling will, within the next 
forty-eight hours, render some change in the form of the splint necessary, or 
compel the surgeon to throw it aside. 

I much prefer to use plain, straight strips of wood, of the requisite width and 
length, which may be cut at any moment from a pine shingle or a thin piece of 
board ; but in order that these splints may adapt themselves to the inequalities 
of the limb, and properly support the fragments, they ought to be covered with 
a muslin sack, open at both ends ; into which, and on the side of the splint 
which is to be placed against the limb, bran, wool, oakum, curled hair, or cotton 
batting may be pressed, until it is made to fit accurately. I generally prefer 
cotton batting. Bran is liable to get displaced, and curled hair does not pack 
firmly enough. When the sack is sufficiently filled, the two ends must be 
stitched up. This mode of constructing the splint is simple and easy of accom- 
plishment; the splint can be fitted very accurately; the padding never becomes 
displaced ; and when the bandages are applied, they may be pinned or sewed to 
the cover in such a way that they shall not slide or loosen. 

If pads are employed separate from the splint — and for this purpose, also, I 
generally prefer the cotton batting — they ought to be made and fitted with the 
same care, and neatly stitched together at their ends, rather than pinned. 
Cotton batting laid loosely next to the skin, or underneath the splints at any 
point, will not keep its place so well as when it is inclosed in covers — it is more 
liable to get into knots, and it has altogether a slovenly appearance. The pads 
may be stitched to the roller, and in this way secured effectually in place, but 
loose cotton is subject to no control. 

When I speak of pads, it must not be understood that I intend to recommend 
them for compresses, or for the purpose of pressing fragments into place. 
Nothing could be a greater source of mischief in the dressing of a broken limb. 
I have only directed their employment as a means of adaptation, and to protect 
the skin against the direct pressure of the splint. 

Dr. Jacobs, of Dublin, says that he has seen an excellent splint made from the 
" fresh bark of a tree, taken off while the sap is rising. " It fits admirably," 
says Dr. Jacobs, "just like pasteboard soaked in water.'' 1 Dr. C. C. Jewett, of 
the 20th Mass. Vols., recommends for the same purpose the bark of the lirioden- 
dendron.'or tulip tree. 

Hemlock-tanned, undressed sole leather, cut into shape and soaked a few min- 
utes in water, adapts itself easily to the limb, and is sufficiently firm. It is 
especially applicable to fractures of the larger limbs. At Bellevue Hospital it 
has for several years taken the place of almost all other materials, for the con- 
struction of movable splints. Oak-tanned leather is less flexible than the hem- 
lock-tanned, and does not make so good a splint. The specimens selected should 
be of medium thickness. Before applying the splint the edges should be bevelled 
on the inner side, and the corners rounded, and a piece of 
woollen cloth should be interposed between the splint and 
the skin. The leather will become hard within twenty- 
four hours, and at the next dressing it may be removed, 
covered with a sack made of woollen or cotton cloth, and 
replaced. Dr. Vance prefers what is known as " bridle 
leather," which is more plastic than sole leather, hardens 
as quickly, and becomes as firm. It can be made very hard 
by substituting hot water for cool in soaking the leather. 

A splint is also occasionally made of thin calfskin, ve- 
neered with "some light timber, such as linden or white 
wood, the latter being subsequently split into strips of from 
half an inch to one inch in width, so as to combine a cer- 
tain degree of flexibility with the requisite firmness. 

The Turks use, according to Sedillot, in a similar man- 
ner, the " nervures " of palm, laid upon sheep-skin, and fas- 
tened with wooden thongs ; 2 and Packard mentions that he has seen narrow 
slips of some light wood glued in the same way upon soft pieces of buckskin 



Fig. 17. 




"Wood and leather 
splint. 



1 Jacobs, New York Journ. Med., March, 1847, p. 265, from Dublin Med. Press. 
" 2 Amer. Journ. Med. Sci., vol. xxiii., Feb. 1839, p. 481. 



GENERAL TREATMENT OF FRACTURES. 65 

and then fastened together with two strips of buckskin, which were also glued 
to the splints. 1 

Common, unpolished pasteboard, cardboard, and the stout millboard used by 
bookbinders, constitute the valuable domestic resorts, since they can generally 
be found in the house of the patient ; and, if in no other way, pasteboard may 
generally be had at the expense of some paper box or of the loose cover of some 
old book. For small bones, the thinner sheets afford a sufficient support; but 
for large bones the thick binder's board is necessary. In preparing the latter 
for use, it ought to be moistened with water ; but if soaked too much it will 
separate and fall into pieces, or lose its firmness when dry, in consequence of 
having parted with some of its paste. This splint may be applied to the limb 
without the interposition of anything but a few folds of muslin cloth or a piece 
of flannel ; or we may use instead a single sheet of cotton-wadding. It must be 
bound to the limb by the roller whilst it is moist; and, as it dries speedily, it 
forms a smooth, firm, and reliable splint. 

Felt, made of wool saturated with gum shellac, and pressed into sheets, makes 
an excellent moulding tablet for splints. This may be obtained at any hat 
manufactory. A much cheaper material, and which has nearly all the qualities 
of the real felt, may be made from old pieces of broadcloth, or from any similar 
closely woven texture, by saturating it thoroughly with gum shellac, the gum 
being dissolved in alcohol in the proportion of one pound of the former to two 
quarts of the latter. Thus prepared, it is to be spread upon both surfaces of the 
cloth with a common paint-brush. When this first coat is well dried by sus- 
pending the cloth where the air will have free access to both surfaces, a second 
must be spread upon one of the surfaces; and then a third ; the cloth being 
allowed to dry after each successive coat. Finally, the sheet is to be folded upon 
itself, so as to bring the most thickly covered surfaces together, and pressed with 
a hot flatiron. If it is necessary to have greater strength, more gum may be laid 
upon the cloth, and it may be again folded and pressed. When used, it is to be 
dipped into boiling water, or held near the fire until it becomes flexible. Shellac 
cloth hardens very rapidly in cooling, and demands, therefore, some quickness 
in its application ; but once applied and fitted, it forms a hard but smooth splint, 
well adapted to all the purposes for which it is designed. It is well to mention, 
if one wishes to keep any portion of the solution which is not used, that, in order 
to prevent evaporation, the vessel in which it is contained must be closely cov- 
ered. Boiling water deprives it of a portion of its shellac, and it is better to soften 
it by holding it to the fire- 
Recently, I have found an article which is better for general use than woollen 
cloth treated with gum shellac. The fabric is lighter, cheaper, and more flex- 
ible. It is made of from four to six layers of cotton cloth, saturated with gum 
shellac and smoothly pressed, and is sold by the manufacturer at the rate of 
about two dollars per yard. At the present time it is used more often by myself 
than any other material for the ordinary purposes of a movable plastic splint, and 
I think is preferred by most of our surgeons. It is light, and, if dipped in hot 
or boiling water for a few moments, it becomes sufficiently flexible to adapt itself 
readily to almost any inequality of surface. Before being cut, a paper model 
should be made from the limb to serve as a pattern. It hardens quickly, but not 
too quickly for accurate adjustment. 

The principal objection to all of those forms of splints which contain gum 
shellac is, they harden so rapidly after being made flexible by exposure to heat, 
that it is often found difficult to give them an accurate mould to the limb. It 
has been objected to the felt splint occasionally, that it is impervious to air and 
moisture, and that it confines the insensible perspiration ; but, as I never use 
splints of any kind without underlaying them with compresses, or woollen cloth, 
which act sufficiently as absorbents, I have never been aware of any inconveni- 
ence from this source. 

Dr. R. O. Cowling, of Louisville, Ky., has called attention to the value of 
Manilla paper in the construction of splints. 2 A limited use of this material 
satisfies me that it possesses most of the qualities of a good splint. It is cut into 

1 Packard's edition of Malgaigne, vol. i. p. 173. 

2 American Practitioner, Jan. 1871. 

5 



66 GENERAL TREATMENT OF FRACTURES 

strips, stiffened with starch, and applied longitudinally or spirally, as maybe 
necessary to cover the limb completely and smoothly. For the lower extremities 
six to eight layers are required. The material may be obtained at most large 
paper stores. 

The employment of gutta-percha as a coaptation splint was first suggested and 
practised by Oxley, of Singapore. For fracture of the thigh, and for the large 
bones generally, I prefer a thickness of about one-sixth or one-fifth of an inch ; 
but for the fingers or toes it need not be more than one-sixteenth of an inch in 
thickness. In its natural state, and at the ordinary temperature of the body, it 
is nearly as hard and as inflexible as bone ; but when immersed in hot water it 
almost immediately softens, and would become too soft to be conveniently handled 
unless soon removed. It can therefore be adapted to any surface, however irreg- 
ular, and its form may be changed as often as may be necessary. It does not 
harden as rapidly as felt, and it possesses, therefore, in this respect, an advan- 
tage, since it allows the surgeon more time for adjustment ; whilst, on the other 
hand, it hardens much more rapidly than either starch, paste, or dextrine. Ten 
or twenty minutes is all the time usually required for gutta-percha to acquire that 
degree of firmness which will prevent it from yielding under the pressure of a 
bandage. To use gutta-percha skilfully requires some experience, and I have 
known surgeons to reject it after a single trial ; but by those who have acquired 
the necessary skill it is generally regarded as an invaluable resource. When 
constructing from this material a thigh-splint, we should order a very large tin 
pan, or some open, flat tray, in which we may lay the splint at full length. If 
the splint is required to be twelve inches long and six inches wide, we must cut 
it about fourteen inches long by seven wide, so as to allow for the contraction 
which always takes place more or less when the hot water is applied. It is then 
to be laid upon a sheet of cotton- cloth of more than twice the width of the splint, 
in order that the cloth may envelop it completely when it is folded upon it ; and 
the cloth should be enough longer than the splint, to enable us to handle and 
lift it by the two ends without immersing our fingers in the hot water. If the 
gum is not thus covered and supported, it will adhere to the vessel, to the fin- 
gers, to the surface of the limb, and indeed to whatever else it comes in contact 
with ; it may even fall to pieces, or become very much stretched and distorted 
by its own weight. The cloth cover will generally adhere to the splint, and may 
be permitted to remain upon it permanently. Place the splint, thus covered, in 
the basin, and pour on the water slowly. As soon as it is sufficiently softened, 
lay it over the limb, moulding it carefully with the hands, or by pressing it 
against the limb with a pillow. If it does not harden rapidly enough, this pro- 
cess may be hastened by sponging the outer surface with cold water ; and as 
soon as it has acquired sufficient firmness to support itself, it may be removed 
and immersed in a pail of cold water or placed under a hydrant ; after this, it 
is to be neatly trimmed and wiped dry, when it is ready for use. When gutta- 
percha remains a long time exposed to the air, it gradually oxidizes, its color 
becomes darker, it loses its tenacity and flexibility. This may be prevented by 
keeping it constantly immersed in cold water. It may be sufficient to place it 
in a damp cellar. 

The same objection has been made to gutta-percha which is occasionally made 
to felt, namely, that it confines the perspiration, but to this I have already suf- 
ficiently replied. There is scarcely any fracture demanding the use of a splint 
in which I have not demonstrated its utility, but it is especially valuable, as I 
shall have occasion to mention again, as an interdental splint in fractures of the 
jaw, and as a moulding tablet in all fractures occurring in the vicinity of joints. 
Immovable or Permanent Dressings.— This class of dressings have now a 
most important place in the treatment of fractures, and deserve careful study. 

In 1834, Seutin, of Brussels, introduced the use of starch as a means of hard- 
ening the bandages ; his method of using which is essentially as follows : A dry 
roller is first applied to the skin, and then smeared with starch ; all of the bony 
prominences and irregularities of the limb are filled up, or covered with cotton 
batting, charpie, down, etc.; strips of pasteboard, or of binders' board moist- 
ened and covered also with starch, are now laid alongside the limb, over which 
again are turned in succession, one, two, or three layers of the starched roller ; 
the number of rollers, and the thickness of the pasteboard being proportioned 



GENERAL TREATMENT OF FRACTURES. 



67 



Fig. IS. 



to the size of the limb or to the required strength of the splint. The whole is 

completed by starching the outside of the last bandage. 

This dressing will generally become dry within from thirty to forty hours ; 

which process may be expedited by exposing its sides as much as possible to the 

air, or by the application of artificial heat with 
bags of dry sand, or with hot bricks. As a tem- 
porary support until the drying is completed, 
some surgeons lay upon each side of the limb 
additional splints, securing them in place with 
tapes. As soon as the bandages are dry, they 
are to be cut along the front to a sufficient ex- 
tent to permit of an examination of the limb, 
and then closed with an additional roller. For 
the purpose of opening the bandages, both at 
this period and subsequently, Seutin uses a 
pair of strong scissors or pliers, such as are 
represented in Fig. 19. On the third or fourth 
day, or as soon as the subsidence of the swell- 
ing may render it necessary, the bandages 
should be cut open through their whole ex- 
tent, the edges pared off and brought together 
again snugly with an additional roller. 

In 1837, Velpeau substituted dextrine {" Brit- 
ish gum ") ; a kind of glue or jelly obtained by 
the continued action of diluted sulphuric acid 
upon starch at the boiling-point. It is pre- 





>tarch bandages applied for a broken 
thigh. 



Seutin's pliers. 



pared for use by dissolving it in alcohol or tincture of camphor, or camphorated 
brandy, until it has acquired about the consistence of honey; at this point 
hot water should be added, reducing its consistence to that of thin treacle, 
when, after one or two minutes' shaking, is is ready for application. According 
to F. d'Arcet, the proportions most favorable to the drying and solidifying of 
the apparatus are, one hundred parts of dextrine, sixty of camphorated brandy, 
and fifty of water. Malgaigne, to whom I am indebted for this observation of 
d'Arcet, says, also, in a note, " As regards dextrine, an important point was 
recently brought practically under my notice, viz., that, as sold in the shops, it 
is often unfit for making an agglutinative mixture ; it forms lumps with alcohol, 
as starch does with cold water, without cohering ; and twice in succession I have 
been obliged to change the supply at the Hopital Saint Antoine. The dextrine 
thus deteriorated is whiter and less saccharine ; it crepitates more in the fingers; 
and on pouring a few drops of tincture of iodine into the solution there is pro- 
duced a violet tint, indicating the presence of fecula ; while true dextrine, treated 
with iodine, gives a vinous red, or the color of onion-peel." The addition of one 
part of common glue to six of dextrine renders the splint more tough. Velpeau 
soaked his bandages with the dextrine before applying them, but, like Seutin, 
he applied his first roller dry. He used but one bandage, which he carried first 
from below upward, and then from above downward; and he rarely thought it 
necessary to employ the pasteboard as a collateral support. 

Tripolith was first introduced by Skenk as a substitute for plaster in the prep- 
aration of bandages. It is a gray powder, composed of lime, silex, and oxide of 
iron. Latelv Lang-enbeck and other German surgeons, and some of the French 



68 GENERAL TREATMENT OF FRACTURES. 

surgeons, including M. Poinsot, have spoken of it quite enthusiastically. It 
hardens much more quickly than plaster, and is much lighter, in both of which 
qualities it resembles dextrine. 1 But Dr. N. S. Nelson, in his inaugural thesis 
at Harvard, declares that he has experimented with it, and that it hardens too 
quickly ; that it is not, as claimed by Langenbeck, impervious to water ; that it 
is expensive, and as a splint "untrustworthy."' 2 

A mixture composed of equal parts of precipitated chalk and gum arable, reduced 
to a proper consistence by boiling water, applied to rollers while they are being 
applied to the limb, forms a firm and light splint. It has the advantage, also, 
of hardening quickly. 

Startin and Tait, of London, recommend paraffine, which, being thoroughly 
melted, is cooled a little, to render it more viscid, and then rubbed into the 
meshes of the bandage, during the process of application with a paint-brush. 

Morgan, of the Middlesex Hospital, uses the best French glue, dissolved in 
water, with a little alcohol ; while Levis, of Philadelphia, has recommended glue 
mixed with a small amount of oxide of zinc, the latter being added to hasten the 
process of hardening. 

Silicate of soda, ofpotassa, or of magnesia, have also been employed in the same 
manner. Of these, the silicate of soda is the least expensive and equally firm, 
but does not harden as quickly as the silicate of potash. A saturated solution 
is prepared, and applied with a brush. It forms a light, firm, and neat spint, 
Wheat-flour paste, if properly made, dries about as quickly as the starch, and is 
equally firm. 

Whatever material is used — whether starch, flour paste, dextrine, 
paraffine, tripolith, solutions of the silicates, glue, gum shellac, or plaster 
of Paris — in the construction of what is now usually termed the " immov- 
able apparatus,'' or, as Seutin has more lately called it, the " movable 
immovable apparatus" ("movo-amobile"), in reference to his practice of 
opening it at an early period, it is still the same apparatus in effect, and 
is liable to the same judgment — a judgment which we shall find it very 
difficult to declare, since from the day in which this practice was first 
recommended by Seutin, to the present moment, it has been constantly 
experiencing the most extraordinary vicissitudes in the public favor ; at 
one time, and by the most experienced surgeons, extolled as a method 
unequalled in its simplicity, efficacy, and safety ; and at another, and by 
surgeons of equal experience, denounced as eminently lacking in all the 
true essentials of an apparatus for broken limbs. These conflicting 
ooinions, which it is impossible to reconcile, have nevertheless some foun- 
dation in truth. The immovable apparatus, of whatever materials con- 
structed, is under some circumstances a very simple, safe, and efficient 
dressing, while under other circumstances it is, as we think, eminently 
unsafe and inefficient. Thus, in all of those fractures which are ac- 
companied with such injury to the soft parts as to render subsequent 
inflammation inevitable or probable, this form of dressing exposes to con- 
gestion, strangulation, and gangrene. Whatever its advocates may say 
to the contrary, the simple fact is before us that the number of accidents 
resulting from this practice is out of all proportion with any other yet 
introduced. I myself have met with them in all parts of my own coun- 
try, and the journals abound with records of disasters from this source. 3 

1 Berliner klinisehe Wochensckrift, 1880. 

2 Nelson, Annals of Anatomy and Surgery, April, 1882. 

'■"> Amer. Journ. Med. Sci., vol. xxv. d. 460, Feb. 1840; also vol. xxxi. p. 212. Med. 
Record, Nov. 1, 1873. New York Med. Journ., Aug. 1874, Oct. 1874. 



GENEEAL TREATMENT OF FRACTURES, 



69 



Nor is it a sufficient reply to this statement that with proper care and pru- 
dence such accidents may be avoided. We think they could not always 
be avoided. But admitting that they could, it is still undeniable that in 
certain cases the immovable apparatus demands extraordinary attention; 




Fig 



Opening of the apparatus with Seutin's pliers. 

and what is the need of multiplying our cares when already they are 
more than sufficient ? Many circumstances, over which he has no con- 
trol, may prevent the surgeon from giving to the limb the full amount of 
attention which is required ; and for this reason 
that apparatus is the best which, whilst it answers 
the indications equally well, exacts the least 
amount of skill and attention on the part of the 
surgeon. 

Immovable dressings are not only liable to 
become too tight as the swelling augments, but, 
on the other hand, the surgeon may omit to 
notice that as the swelling has subsided it has 
become loose. Portions of the limb may vesi- 
cate, ulcerate, or even slough, without the knowl- 
edge of the surgeon. If, however, the bandages 
are frequently opened, and all the proper pre- 
cautions are taken, it is possible that these acci- 
dents may also be avoided ; but unfortunately 
experience has shown that they have not been 
avoided in too many instances. 

The cases, then, to which this apparatus seems 
to be especially adapted, are a few examples of 
transverse or serrated fractures in which the 
bones have not become displaced, and in which 
little or no swelling is anticipated ; and certain 
fractures which were originally more complicated, 
but in which a partial union, and the subsidence 
of the inflammation, have reduced them to a 

more simple condition ; and especially is it adapted to cases of delayed 
union. If now the dressings are applied carefully, the bandage being- 
only moderately tight ; and a portion of the extremity of the limb is left 




" Apparatus immobile " 
applied over a compound 
fracture. 



70 GENERAL TREATMENT OF FRACTURES. 

uncovered so that we may observe constantly its condition, and at proper 
intervals the apparatus is opened completely, in order that we may sub- 
ject the Avhole limb to a thorough examination ; in such cases as I have 
now indicated, and with such precautions, I admit that the " apparatus 
immobile" constitutes an invaluable surgical appliance, and one of which 
no surgeon can well afford to be deprived. 

I have also met with examples of compound fractures in which it has 
seemed proper to apply this dressing ; and especially when a sufficient 
time had elapsed to render it probable that there would be no sudden 
accession of swelling in the limb. In such cases I have preferred gener- 
ally to lay the several turns of the roller directly over the suppurating 
wound in the same manner as if no wound existed, and to make a valvu- 
lar opening, or window, with the scissors, on the following day, in order 
to allow the matter to escape, after which the valve may be laid down 
and stitched, or the piece may be removed entirely, and a new piece of 
bandage drawn closely around the limb at this point. This may be 
repeated once or twice daily. If an opening is left by the roller, and no 
additional bandage or compress is laid over it, the margins of the wound 
soon became oedematous and protrude, making an ugly-looking and ill- 
conditioned sore. 

Plaster of Paris has, however, been from a later period employed in another 
form, as an "immovable" dressing. I allude to the so-called " plaster-of-Paris 
bandages/' which were first introduced to notice by Mathiesen, of Holland, in 
1852. In 1854, Pirogoff, surgeon in chief of the Russian armies, called attention 
to the plaster-of-Paris dressing, but in a form differing somewhat from that 
employed by Mathiesen. 

At Bellevue, during six or seven years, Paris-of-Paris bandages were used 
quite extensively, and, after a careful observation of the results in my own wards, 
and in the wards of my colleagues, I find no occasion to recall anything I have 
said of this, as one form of the immovable apparatus, in the preceding pages ; 
the dangers have not been over-estimated, yet I must say that in fractures of the 
leg, whether simple or compound, when great care is exercised in the manage- 
ment of the case, it is, in some respects, superior to any other form of dressing. 
I shall describe the cases to which it is applicable, more particular, when speak- 
ing of these fractures. At the present moment the use of plaster of Paris as a 
dressing for fractures is very little in favor with most of the Bellevue surgeons, 
except in fractures of the tibia and fibula. 1 

The manner of using gypsum bandages, generally preferred at Bellevue Hos- 
pital, may be thus briefly described. Thin, rather coarse, unglazed cotton cloth, 
torn into strips, is laid upon a table and the dry plaster rubbed into it until its 
meshes are full. It is then rolled, and made ready for use by immersing it a 
few minutes in hot water. The limb, being held in a proper position, is first 
inclosed in soft, dry flannel cloth, and the rollers are then applied. In most 
cases two or three thicknesses of bandage are found to be sufficient. A more 
full description of this method, known generally as Mathiesen's, will be found 
in the chapter devoted to the consideration of fractures of the femur. 

Another method of using the gypsum bandages, not generally practised at 
Bellevue, is as follows : A dry roller is first applied to the limb, or it may be 
covered with a single piece of cloth of any kind, and the irregularities are 
filled up and protected with cotton-wool, the same as we have directed when 

1 Treatment of Fractures of the Femur by the Immovable Apparatus, by the author. 
New York Med. Journ., Aug. 1874. A comparison of the results of treatment of 308 frac- 
tures of the thigh at Bellevue Hospital, by Frederick E. Hyde, M.D., New York Journ. 
Med., Oct. 1874. 



GENERAL TREATMENT OF FRACTURES 



71 



about to apply the starch bandage. The remaining dressings being now at 
hand and ready for use, we proceed to mix the plaster. For this purpose we 
must select the fine, fresh, well-dried, white powder. The gray does not solidify 
well, nor that which has been a long time ground, or is moist. The proportions 
of water and plaster usually required are about equal parts by weight. - For the 
thigh it may require, perhaps, seven or eight pounds of plaster, and for the leg 
or arm much less. It is probably a better rule to direct the gypsum to be added 
to the water until it is of about the consistence of cream. The water should 
be cold and the gypsum thrown in not too rapidly, at least not more rapidly 
than it can be thoroughly mixed, otherwise we shall not be able to determine 
precisely its consistence. If, while applying the paste, it begins to harden in 
the bowl, we must not add more water, as this will again interfere with its final 
solidification upon the limb. It must be thrown away and some fresh imme- 
diately prepared ; or the crystallization may be retarded by throwing in a few 
drops of carpenter's glue, or a little starch, dextrine, or glycerin. The solidi- 
fication may be hastened by adding a little salt to the water. When the plaster 
is good, and it is properly mixed, we may allow ourselves from five to eight 
minutes in the application. A large paint-brush is the most convenient thing 
for spreading it, but the hands will do very well in an emergency. 

Everything being ready, the limb is to be seized by assistants at both of its 
extremities and held in a position of steady extension until the dressing is com- 
pleted, and for several minutes longer, or until the plaster is hard. The surgeon 
then proceeds to lay a long piece of linen — old sack will answer as well as any 
— folded three or four times, and saturated with the paste, parallel to the two 
sides of the limb, around which are to be immediately placed, horizontally and 
at several points, short and wide strips of the same material. These latter are 
intended to increase the strength of the apparatus, and to bind on. the side 
strips. Finally, the whole may be painted with the solution. It is very well, 
however, not to cover the front of the limb, or a narrow strip somewhere in the 
line of the axis of the limb, with the plaster, as this will not diminish materi- 
ally its strength, and it will enable the surgeon to open it more easily with the 
scissors. Pirogoff accomplishes the same purpose by laying a piece of narrow 
tape, soaked in oil, along the line through which he wishes to make the section 
of the splint. 1 

Little, of New York, makes his plaster splints of two or three thicknesses of 
muslin, or of canton flannel, which being saturated with fluid plaster, are laid 
upon the limb previously shaven and oiled, and secured in place with a roller. 
He advises that the roller shall be removed as soon as the plaster is set and a 
fresh one applied, which can afterward be easily removed. 2 

Fig. 22. 




Von Brian's plaster cutter. 

In removing the plaster we generally employ a shoemaker's knife, softening 
the plaster as we proceed with a sponge dipped in hot water. As cutting pliers 



1 Weber on Plaster-of- Paris Bandage, New York Journ. Med., May, 1856, p. 341. 

2 On the Use of Plaster of Paris in the Treatment of Fractures, by James L. Little, Sur- 
geon to St. Luke's Hospital, etc., Med. Record, Nov. 1, 1873. 



72 GENERAL TREATMENT OF FRACTURES. 

for this purpose, no instrument has been found sufficiently powerful except that 
introduced by Dr. Victor von Brim, of Tubingen. 

Professor B. W. Dudley, of Lexington, Ky., one of the most successful 
surgeons in this country, but especially distinguished as a lithotomist, for 
many years employed in the treatment of fractures nothing but a roller, 
regarding both side-splints and extending apparatus as not only useless, 
but absolutely pernicious. 1 This practice, which seems to have originated 
with Radley, of England, has not found, hitherto, in this country or 
elsewhere, many imitators. 

Still more unscientific and irrational was the practice of Jobert, of 
Paris, who employed neither side-splints nor bandages, but only exten- 
sion, in the treatment of all, or of nearly all fractures of the long bones. 
The side or coaptation splints bring the fragments into more complete 
apposition, and secure a more prompt and certain union. They ought, 
therefore, never be omitted, unless the condition of the limb precludes 
their application. 

As to the question of permanent extension in fractures, and the means 
by which it may be most effectually accomplished, nothing need be said 
at this time, inasmuch as it relates only to the fractures of certain bones, 
and to certain forms of fractures ; we must therefore refer its considera- 
tion to those chapters which treat of individual bones. 

In the treatment of comminuted fractures, no pains ought to be spared 
to bring the fragments as nearly as possible into apposition ; and if there 
exists at the same time an external wound, and the fragments are small 
and loose, they ought to be removed carefully. Nor, indeed, should we 
be deterred from the attempt to remove them by finding that they are 
somewhat adherent, if still they are very easily moved about with the 
finger. 

In compound fractures, not unfrequently the end of one of the frag- 
ments protrudes from the wound, and its reduction may be attended with 
considerable difficulty. My practice is usually in such cases to attempt 
the reduction first, by simple extension and counter-extension ; but if 
this fails, a finger is introduced into the wound, and an attempt is made 
to stretch the skin over the sharp point of bone ; or a spatula is used, 
formed from a piece of wood, or of any suitable piece of metal which 
may be at hand ; finally, but not until all other expedients have failed, 
the wound is enlarged sufficiently to insure its return. Anaesthetics 
may be employed, also, to facilitate the reduction. 

There are some cases, however, in which the surgeon may feel justified 
in sawing off the projecting end; as when the periosteum is completely 
torn from it by its having penetrated a boot, or even sometimes when its 
extremity is very sharp, and there is reason to suppose that it would 
prick and irritate the tissues. In these cases, also, surgeons have pro- 
posed to secure the fragments in apposition by metallic ligatures or 
sutures. In a few instances the practice has been attended with success, 
but in most cases the wires have failed utterly of their purpose, and have 
only proved sources of additional irritation. 

1 Dudley, Trans. Amer. Med. Assoc, vol. iii., 1850, p. 349. 



GENERAL TREATMENT OF FRACTURES. 73 

Ruptured arteries, if within reach, ought always to be tied; and if 
arteries situated remote from the surface bleed freely and for a long time, 
we may make some effort to find the open mouths in the wound ; but in 
this we rarely succeed, nor is it safe generally to trust to a ligature of 
the main branch which supplies the limb. Fortunately, this bleeding, 
although at first profuse, generally ceases in a few hours under the steady 
employment of cold lotions, moderate compression, and rest. If it does 
not, the chances are that the case will call for amputation. 

To ligate the main arterial trunk which supplies the injured limb, as 
suggested by Poinsot, would, in my opinion, expose the life of the patient 
to greater dangers than to amputate the limb. Under such circumstances, 
with the limb bruised and infiltrated with blood, to cut off its main 
arterial supply would render the occurrence of gangrene almost inevitable. 
Compression at the point of lesion and upon the main artery, at the same 
time, as suggested also by Poinsot, would insure the same result. 1 

Bones Badly United. — Bones which have united with serious deformity 
are occasionally refractured for the purpose of securing a more comely 
or a more serviceable limb. This may be done when the union is recent 
and the callus and adjacent tissues are vascular, with almost an assurance 
of a prompt union. Indeed, if the bone be refractured within four or 
eight weeks after the occurrence of the original fracture, it will in general 
unite more speedily than at first ; and this is especially true in the case 
of children ; but if the refracture be delayed much beyond the latter 
period, the chances of prompt reunion become lessened, and after the 
lapse of several months or years the danger that a refracture will result 
in only a fibrous union is considerable. In the case of an old fracture it 
becomes therefore a question, whether the deformity and maiming are 
sufficient to warrant the surgeon in assuming the risk that it may not 
unite at all, or that it may result in a fibrous union. The cause of this 
delay and uncertainty in the proper union after refracture of bones which 
have been long united, is probably the fact that the bond of union be- 
comes at length harder than the original bone, and although it may 
break as easily as, or even in most cases more easily than, the natural 
bone, it is less vascular, and the tissues adjacent are also perhaps less 
vascular, having undergone certain textural or cicatricial changes in 
consequence of the original lesion. 

In deciding this question, then, we will be governed by the degree of 
deformity and maiming, by the time which has elapsed since the union, 
by the general condition of the patient as to constitutional vigor and 
capacity of repair, and especially by the bone, or the portion of the 
bone, which is the seat of the deformity. Refractures of the shafts of 
the humerus and of the femur are less likely to unite by bony callus, 
than refractures of the forearm or leg. If only one bone is broken in 
the forearm or leg, the danger of non-union after refracture is lessened, 
and, especially if the lower end of the radius is the part involved. 

There is one popular error in reference to refracture, and indeed the error is 
by no means confined to the laity, namely, that by a refracture at any period 
after four or six weeks we can materially add to the length of the limb. The 

1 Poinsot, French edition of this work, p. 55. 



74 DELAYED AND NON-UNION OF BROKEN BONES. 

permanent contraction of the muscles which by this time has taken place,. the 
presence at an early stage of inflammatory effusions, and at a later stage of ad- 
hesions, will in most cases effectually prevent any considerable elongation of 
the limb. It may be lengthened by being rendered more straight, and in a 
small degree perhaps by actual stretching of the soft tissues, but this is all that 
can be reasonably promised or expected, in a large majority of cases. 

In general, no fear need be entertained that the refracture will en- 
danger the life of the patient, unless the fracture involves a joint. No 
doubt death may have been caused in this way, but a scientifically con- 
ducted refracture is vastly less likely to cause death than the original 
accident. Nor need we generally fear that the bone will break at any 
other point than at the place of the old fracture, provided at least we 
take proper care to make the pressure at the right point. 



CHAPTER VII. 

DELAYED UNION, FIBROUS UNION, AND NON-UNION OF 
BROKEN BONES. 1 

Muhlenberg, of Philadelphia, has made a very valuable contribution 
to this subject in a collection of cases drawn from the medical journals, 
and published in a tabular form by Dr. Agnew in his treatise on surgery. 
In a summary of the whole number, 656 cases, it is stated that 565 were 
males and 91 females. The youngest was 13 years old and the oldest 
70, the largest number being within 28 and 40 years. In 61 the frac- 
tures had existed less than three months ; the shortest period being three 
weeks, and the longest ten years. The whole number cured by the 
various plans of treatment was 385 ; of the remaining 271, 43 were re- 
lieved — that is, the amount of motion between the fragments was lessened 
— in 204 no benefit was derived from the operation, 19 proved fatal, and 
in 5 the result is not known. 

Causes and Varieties. — Most surgical writers concur in the statement 
that non-union of broken bones is an uncommon event. 

Walker, of Oxford, affirms that of not less than one thousand fractures which 
have come under his treatment at some period of the repair, he does not recol- 
lect more than six or eight instances. According to Lonsdale, not more than 
five or six cases of false joint, excepting those within a capsule, have occurred 
out of nearly four thousand fractures treated at the Middlesex Hospital. In a 
table of 367 cases, collected and arranged by W. W. Morland, from the books of 
the Massachusetts General Hospital, extending through a period of nineteen 
years, only one example of false joint is recorded ; but as only seventy-four days 
had elapsed when this patient was discharged, it is doubtful whether this might 
not have proved to be a case of delayed union simply. 2 In 946 cases of recent 

1 I shall in this chapter avail myself freely of the labors of George W. Norris, of Phila- 
delphia, whose paper, entitled " On the Occurrence of Non-union after Fractures, its Causes 
and Treatment,'' published in the American Journal of the Medical Sciences for Jan. 1842, 
constitutes one of the most complete and reliable monographs upon this subject contained 
in any language. 

2 Address on Fractures, by A. L. Pierson, read before the Massachusetts Med. Soc, May 
27, 1840. 



DELAYED AND NON-UNION OF BROKEN BONES. 75 

fracture treated in the Pennsylvania Hospital, between the years 1830 and 1840, 
there was no instance of false union. 1 Sir Stephen Hammick, Mr. Liston, and 
Malgaigne affirm also the infrequency of these accidents in the cases which have 
come under their personal treatment. I myself have seen a large number of 
examples of non-union, but in not one of my own patients, whether in hospital 
or private practice, except in cases involving joints, has the bone refused finally 
to unite ; and my opinion is that, in proportion to the number of fractures 
everywhere, these cases are very rare, perhaps not in a larger proportion than 
one in five hundred. 

The humerus and femur would appear to be the bones most liable to 
non-union, as shown b}^ Norris's statistics ; in which forty-eight belonged 
to the humerus, forty-eight to the femur, thirty-three to the leg, nineteen 
to the forearm, and two to the jaw. I have found the humerus ununited 
more often than the femur. 

Berard has shown that in the growth of the long bones the period at which 
the epiphyses are united to the diaphyses depends upon the direction of the 
nutritive artery; for example, "It is found that in the humerus, where the 
direction of this vessel is from above downward, consolidation takes place 
soonest at its inferior extremity. In the forearm the course of the nutrient 
vessels is from below upward, and here consolidation of the epiphyses is found 
to occur at the elbow sooner than at the wrist. In the inferior members, on the 
contrary, the epiphyses composing the knee are the last which become firm, 
because in the femur the nutritious artery runs upward, and in the bones of the 
leg it courses from above downward." A knowledge of these facts led Gueretin 
to inquire into the influence of these arteries upon the consolidation of fractures ; 
and the cases collected by him did indeed seem to show a positive relation be- 
tween the direction of the artery and the union of the bone : that is to say, the 
examples of non-union were chiefly found where the fracture had taken place 
on that side of the nutritious foramen from which the artery entered, as if to 
imply that the non-union was in some measure due to the imperfect nutrition 
of this extremity of the bone. In thirty-five cases of non-union analyzed by 
Gueretin, ten belonged to that portion of the bone which was traversed by the 
artery, and twenty-five to the other portion. But an analysis of forty-one cases, 
made by Norris, does not seem to confirm this observation of Gueretin, since 
twenty-seven were in the direction of the nutritious arteries, and only fourteen 
in the opposite portion, or in that which is supposed to be less nourished. 

Another observation, made by Curling, that in fractures of the long bones the 
portion below the entrance of the nutrient artery, or on that side of the nutrient 
foramen toward which the blood flows, being defrauded of its proper supply, is 
subjected to a species of atrophy, presenting a larger medullary canal, with 
thinner walls, and a spongy tissue less dense, also needs confirmation. Malgaigne 
has not noticed this fact in any of the specimens contained in the public museums 
of Paris. 

According to Norris, there are four principal kinds of false joint : 
In the first, the bones are united and completely enveloped in a car- 
tilaginous mass or callous tumor, but, in consequence of some retardation 
in the process, bony matter is not deposited, and, as a consequence, it 
wants solidity, the part continuing easily movable. This may be re- 
garded as a proper example of delayed union, as distinguished from 
complete non-union, or false joint. 

In the second, there is entire want of union of any sort between the 
fragments, the ends of which seem to be diminished in size and extremely 
movable beneath the integuments. The limb in these cases is found 
wasted and powerless. 

1 Norris, loc. cit. 




76 DELAYED AND NON-UNION OF BROKEN BONES. 

In the third and most common class, the medullary canal is obliterated 
in both fragments, and the ends are more or less absorbed, rounded, and 

covered, in part or in whole, with a 
FlG - 23 - dense tissue resembling the periosteum. 

A connection also exists between the 

opposing fragments in the form of 
Clavicle united by ligamentous bandT strong ligamentous or fibro-ligamen- 

tous bands, which, if of any length, 
are quite flexible, and allow of considerable motion at the seat of 
fracture. 

In the fourth, " a dense capsule without opening of any kind, contain- 
ing a fluid similar to synovia, and resembling closely the complete liga- 
ments, is found." In these cases the points of the bony fragments 
corresponding to each other are rounded, smooth, and polished, in some 
instances eburnated, and in others covered with points or even thin plates 
of cartilage, and a membrane closely resembling the synovial of the 
natural articulation. It is in this kind of cases, Norris remarks, that 
the member affected may still be of use to the patient, the fragments 
being so firmly held together as to be displaced only upon the applica- 
tion of considerable force. 

The existence of the newly formed joints, or true diarthroses, has been called 
in question by Boyer, Hewson, Chelius, 1 and others; but the observations of 
Sylvestre, Brodie, Beclard, Home, Howship, Otto, Kuhnholtz, Houston, Cooper, 
Langenbeck, Feraud, and Breschet prove that such examples are occasionally 
found. 2 I myself have met with several examples. 

The causes of delayed union and of non-union are either constitutional 
or local. 

The constitutional causes are chiefly those conditions of the general 
system which manifest themselves by anaemia, debility, or some peculiar 
dyscrasy. 

Syphilis in the system has seemed to prevent the formation of callus. 
Such is the opinion of Sansom, Beulac, Condie, 3 and many others. 

Lagneau and Oppenheim 4 incline to the opinion that syphilis exerts in this 
respect but little influence ; and even Berard, who admits the pertinence of one 
case observed by Nicod, concludes, after numerous researches, that it has been 
very rarely shown to affect the formation of callus. 5 

Pregnancy and lactation have been known to interfere with the union 
of bones. 

1 Malad. Chirurg., t. iii. p. 103, Paris, 1331 ; North Amer. Med. and Surg. Journ., No. ix. 
p. 7, 1828; Trait, de Chir., trad, par Pigne, p. 150, 1836. (Norris, loc. cit.) 

2 Nouvelles de la Repub. des Lettres de Bayle, p 718, 1685 ; Lond. Med. Gaz., xiii. p. 57, 
1833; Beclard, Gen. Anat., trans, by Hay ward, pp. 149,248; Transac. Med.-Chir. Soc. of 
Edinburgh, i. p. 233, 1793; Med.-Chir. Trans., viii. p. 517, 1817; Otto's Path. Anat., trans, 
by South, i. p. 138; Journ. Complement, iii. p 291 ; Dub. Med. Journ., viii. p. 493 ; Cooper 
on Frac. and Disloc, fourth London ed., p. 508; Recherch. sur les Formation du Cal, 1819, 
p. 34. (Norris, loc. cit.) 

3 Diet, de Med. et Chir. Prat., iii. p. 492; Journ. de Med. Chir. et Pharm., t. xxv. p. 216. 
(Norris, loc. cit.) 

4 Expose des symp. de la mal. Ven., p. 525 ; Oppenheim on False Joints, 1837. (Norris, 
loc. cit.) 

5 Op. cit., p. 21. 



DELAYED AND NON-UNION OF BROKEN BONES. 77 

Werner, Hildanus, Wilson, Hertodius, Alanson, Bard, of New York, and 
Condie, of Philadelphia, 1 have all reported examples, in some of which the 
process of union was resumed and brought to a rapid completion as soon as the 
period of pregnancy was closed, or when lactation ceased ; but three cases re- 
ported. by Sir Stephen Love Hammick would seem to show, what, indeed, other 
evidences render probable, that the delay was less due to the fact of the preg- 
nancy and the lactation than to the debility occasionally consequent upon these 
conditions. 2 

As to the question whether cancer ever causes a delay in the union 
of bones, it may be said that where the fracture arises in consequence 
of a true cancerous deposit around or in the interior of the bones, pro- 
ducing absorption of their tissue, no union takes place ; but that the 
mere presence of the cancerous cachexy does not usually prevent the 
formation of callus. 

Scurvy, fevers of a low type, and, on the other hand, fevers of a highly 
inflammatory character, profuse uterine and vaginal discharges, and 
rhachitis, conduce to the same result. 

The withdrawal of an habitual stimulus, and especially a change from 
a good to a low diet, or copious bleedings, may either of them delay the 
deposit of ossific matter, or prevent it altogether. 3 

Bonn has furnished two cases in which advanced age seemed to have 
retarded the formation of callus, but Horner saw a fracture of the humerus 
in a woman ninety years old unite in five weeks. 4 I myself have noticed 
a good many similar examples in advanced life, and it is now rendered 
quite probable that surgeons have generally over-estimated the influence 
of old age upon the formation of callus. 

The local causes are, arrest of the arterial circulation by bandages ; 
arrest of the venous circulation by pressure, by rupture of veins, or by 
the formation of venous clots ;° paralysis or impairment of the nervous 
circulation ; the occurrence of the fracture within a capsule ; obliquity 
of the fracture ; overlapping of the fragments ; interposition of a piece 
of bone, of a tendon, muscle, or of a clot of blood, or separation of the 
fragments from any cause whatever ; erysipelas ; acute phlegmonous 
inflammation ; suppuration ; necrosis ; too much motion ; exclusion of 
light and air inducing local scurvy : wet, and especially cold and moist 
dressings ; too early use of the limb, etc. 

Treatment. — In order to hasten the consolidation when it is simply 
delayed, we resort to all of those expedients which are calculated to in- 
vigorate the general system ; and for this purpose the employment of a 
nutritious diet and the use of mineral or vegetable tonics may not be 
properly omitted; but in our experience nothing has proved so efficient 
as encouraging the patient to leave his bed and get out into the open air; 
for which purpose, if the fracture is in the low T er extremities, crutches 
will be necessary. 

As local means, we may enumerate first the removal of those local 

1 Cooper's Diet., ed. 1838, p. 546; Opera Hild., 1681 ; Wilson on the Human Skeleton, p. 
214: Bib. Choisie cle Med., xxiv. p. 595: Med. Obs. and Inquiries, 4, 1772. 

2 Practical Remarks on Amputations, Fractures, etc , p. 121. (Norris, loc. cit.) 

3 Norris, loc. cit. 
i Ibid., p. 29. 

5 George W. Callender, Brit. Med. Journ., Nov. 30, 1872. 



78 DELAYED AND NON-UNION OF BROKEN BONES. 

causes which seem to have interfered with the consolidation or with the 
union. If the fragments have been officiously disturbed, it may be 
sufficient to impose upon the limb absolute rest for a certain length of 
time ; and the fragments may be more closely pressed against each other ; 
in other cases it will be found necessary to remove the bandages, expose 
the limb freely to the light and air at least once or twice daily, and to 
rub it gently with the dry hand or with some moderately stimulating oil, 
so as to induce a more healthy condition of the soft parts, and encourage 
the natural circulation. Moving the fragments freely upon each other, 
sufficient to determine a degree of excitement in the adjacent tissues, and 
upon the opposing surfaces of the bones, and then confining them during 
one or two weeks in firm and well-fitting splints, will sometimes succeed 
when other means have failed. 

Indeed, I may say that by one or another of the simple methods now enu- 
merated I have never failed, sooner or later, to effect consolidation in recent 
fractures ; and it has only been in fractures of at least four, six, or eight months' 
standing that I have been compelled to resort to more extreme measures. As 
a means of combining immobility with compression and healthful exercise, the 
apparatus immobile in many of its forms, is peculiarly adapted. White, of 
Manchester, employed a firm leather sheath for the thigh. H. H. Smith, of 
Philadelphia, 1 recommends a more complex artificial support, upon which the 
limb may be allowed to rest while in the act of progression. With some sur- 
geons, the object of allowing the patient to walk, in fractures of the thigh or 
\eg, is chiefly to excite in the tissues adjacent to the seat of fracture some degree 
of inflammatory action ; but which, as the result in one of White's patients has 
sufficiently shown, may be carried too far, and even determine suppuration. 

Dr. E. D. Hudson, artificial limb maker, of New York, has applied in similar 
cases, which have come under my observation, an apparatus of his own construc- 
tion, made of willow, and secured in place by leather straps. In case the 
purpose of the apparatus is to encourage bony union, no motion is allowed at 
the knee-joint. 

Becently, also, Tiemann and Stollman have adapted to one of my patients 
successfully an apparatus of their own construction. This was a case of ununited 
fracture of the femur, of long standing, and in which I had succeeded by the 
use of Brainard's drills, the gimlet, and other operative procedures, in securing 
a very close and firm fibrous union. The fibrous band became finally converted 
into bone, after the lapse of a few months, while walking with crutches, the 
limb being supported by Mr. Tiemann's very ingenious apparatus. 

Blisters, mustard cataplasms, the tincture of iodine, 2 caustics, 3 etc., applied ex- 
ternally over the seat of fracture, can have no other effect than to increase 
moderately the congestion of the tissues, and in so far they may aid in the 
accomplishment of the bony union ; but in this respect they are inferior to the 
violent twistings, flexions, and rubbings of the broken ends of which we have 
already spoken. 

Electricity was first employed by Mr. Birch, of London, but Dr. Valentine 
Mott obtained no effect from it in two cases in which he seems to have given it 
a fair trial. 4 Lente, of the New York Hospital, has furnished an account of 
three cases treated in that institution by electricity in connection with acupunc- 
turation; the mode of using which was to pass a needle down to the periosteum 
on each side of the bone, and to attach the poles of the battery to these opposite 
points. Lente thinks that electricity employed in this way is much more effi- 
cient than when the poles are merely applied to the surface. He informs us, 

i H. H. Smith, Amer. Journ. Med. Sci.. Jan. 1855, Jan. 1876. 

2 Hartshorne, Eclectic Eep., vol iii. p. 114, 1813. 

3 Willoughby, Amer. Journ. Med. Sci., Aug. 1834, p. 444. 
* Mott, Med. and Surg. Eep., pp. 21, 375. 



DELAYED AND NON-UNION OF BROKEN BONES. 



79 



also, that other cases than these now reported have been treated successfully in 
this hospital by means of electricity. 1 

Mercury will no doubt prove serviceable occasionally by virtue of its powers 
as an anti-syphilitic, but its beneficial influence in other cases is far from having 
been established. 



Fig. 24. 



Fig. 25. 





Tiemann & Co.'s apparatus for ununited 
fracture of the femur. 



Physick's first ease, after 28 years. 
(From Amer. Journ. Med. Sei.) 



The seton is said to have been first suggested by Winslow, in 1787 ; but, what 
is of much more consequence, the credit of its first successful application and 
its general introduction into practice is due to Dr. Philip Syng Physick, of 
Philadelphia, by whom it was employed in 1802. 2 Physick used for his seton, 
generally, silk ribbon or French tape; and this he introduced, by means of a 
long seton needle, between the ends of the fragments. He recommended that 
the seton should remain in place four or five months, and longer if necessary, 
and it was his opinion that the failures were generally due to its being removed 
too early. At the present day, however, surgeons who employ the seton think 
it serves its purpose better when it remains in place but a few days, not longer, 
perhaps, than ten or fifteen, always taking care that it is removed before ex- 
cessive suppuration is induced. It has been found especially valuable in frac- 
tures of the inferior maxilla, clavicle, and of the upper extremities ; but in the 
case of the femur it has so frequently failed, that Dr. Physick himself did not 
recommend its use. 



1 Lente, New York Journ. Med., Nov. 1850, p. 31^ 

2 Physick, Med. Piepository of New York, vol. i., 



804. 



80 



DELAYED AND NON-UNION OF BROKEN BONES. 




Dieffenback's drill for 
ununited fracture. 



In case the seton cannot be passed directly between the opposing fragments, 
as recommended by Physick, we may adopt the practice suggested by Oppen- 
heim, and carry two setons, one on each side, close to 
the bone. 

Somme, of Antwerp, preferred a loop of wire to the 
silk seton employed by Physick. 1 Seerig passed a liga- 
ture around the ligamentous mass connecting the two 
fragments, and then proceeded to tighten the ligature 
until it fell off. 2 Dr. Hulse, of the U. S. Navy, em- 
ployed stimulating injections with success in a case of 
non-union, accompanied with an external and fistulous 
opening. 3 In 1848, Dieffenbach recommended that 
ivory pegs be introduced into holes previously made in 
the bone 4 by means of a gimlet or drill, and Mr. Stanley 
has succeeded once by this method. 5 Mr. Hill intro- 
duced the ivory pegs in a case of ununited fracture of 
the femur, pyaemia supervened, and the patient died. 6 

Malgaigne, in 1837, tried to introduce acupuncture 
needles between the ends of an ununited fracture, but, 
although he thrust the needle down to the bone thirty- 
six times, he was unable to make it pass once between 
the ends of the fragments. Wiesel succeeded better. 
In a case of ununited fracture of the ulna, of nine 
weeks' standing, having passed two needles between 
the fragments, at the end of six days, the needles being 
removed, consolidation rapidly ensued. 7 This practice 
does not differ essentially from the metallic hoop of Somme. It is only a 
modification of the seton. 

Brainard, of Chicago, has attempted to show that setons of any kind, whether 
of wood, ivory, or metal, placed in contact with the bone, occasion absorption, 
caries, and necrosis, but that they never directly give rise to bony callus ; and 
that the occasional success of the seton, which success he believes to have been 
greatly exaggerated, has not resulted from any tendency to favor the formation 
of callus, but from the induration and tenderness of the soft parts produced by 
it ; circumstances which, by conducing to rest, indirectly favor the consolida- 
tion. 8 

[The seton, as a remedy for non-union of bones, has been superseded by anti- 
septic operations of far greater certainty in securing union; and free from 
danger. The most important of these operations is the wiring of the fragments.] 
In May, 1848, Miller, of Edinburgh, reported five cases treated successfully 
by subcutaneous puncture. The operation consisted in passing the point of a 
needle or small tenotomy bistoury down upon the ends of the bone, and freely 
irritating the surfaces at several points. 9 George F. Sandford, of Davenport, 
Iowa, has successfully imitated this practice in two cases. 10 

In 1850 Dr. William Detmold, of New York, performed the operation of 
drilling or perforating the fragments in a case of ununited fracture of the tibia, 
employing for this purpose a large gimlet. He first bored two holes between 
the opposing fragments, and then, introducing the gimlet one and a half inch 
below the fracture, he penetrated the tibia upward and inward until he had 
traversed, also, the upper fragment to the extent of an inch. In three weeks 
the bone appeared firm, but from this time the patient was not seen. 11 



1 Amer. Journ. Med. Sci., vol. vii. p. 497. 2 Norris, loc. cit., p. 46. 

3 Hulse, Amer. Journ. Med. Sci., vol. xiii. p. 374. 

4 Malgaigne, trans, by Packard, op. eit., p. 258, note. 

5 Stanley, New York Journ. Med., Nov. 1854, p. 441, from Dublin Press. 

6 New York Med. Gaz., July 4, 1868, from the London Lancet. 

7 "Wiesel, Amer. Journ. Med. Sci., vol. xxxiv. p. 254, July, 1844. 

8 Brainard, Trans. Amer. Med. Assoc, vol. vii., 1854; Prize Essay. Eeport on Surgery 
to Illinois State Med. Soc, May, 1860. 

9 Miller, New York Journ. Med., July, 1848, p. 134. 

10 Sandford, Trans. Amer. Med. Assoc, vol. iii. p. 355, 1850. 
" New York Med. Gazette, Oct. 12, 1850. 



DELAYED AND NON UNION OF BROKEN BONES. 81 

Brainard employs for this same purpose a strong metallic perforator, consist- 
ing of a handle, into which points of different sizes may be inserted, and which 
have been hardened so as to penetrate the hardest bone or even ivory in every 
direction easily. The points are "somewhat awl-shaped; but more pointed in 
the middle rather than like a drill, which leaves chips.'' His manner of using 
this instrument is as follows: "In case of an oblique fracture, or one with over- 
lapping, the skin is perforated with the instrument at such a point as to enable 
it to be carried through the ends of the fragments, to wound their surfaces, and 
to transfix whatever tissue maybe placed between them. After having trans- 
fixed them in one direction, it is withdrawn from the bone, but not from the 
skin, its direction changed, and another perforation made, and this operation 
is repeated as often as may be desired." Dr. Brainard, who succeeded by this 
procedure in a number of cases of ununited fracture, thinks it better to com- 
mence in most cases with not more than two or three perforations, in order that 
the effect produced shall not be too severe. It is scarcely necessary to add that, 
after the punctures have been made, the limb should be put completely at rest 
in appropriate splints, or in apparatus of some kind. 

Fig. 27. 




Brainard's perforator, reduced one-half. 

I have recently employed, as an addition to the surgical procedures above 
enumerated, common shawl-pins, of steel, about four or six inches in length, 
having glass heads. Several of these are thrust between the ends of the bone, 
and are left in place seven or ten days; to be inserted again from time to time 
as may seem desirable. 

Scraping or rasping the ends of the bones is a practice which dates from a 
very early period. Mr. Brodie scraped the ends of the bones, and then inter- 
posed a bit of lint. 1 Mayor, in 1828, contrived to introduce an iron, previously 
heated in boiling water, through a canula, and thus brought the heat to bear 
directly upon the ends of the fragments ; and, by repeating the application 
several times, a cure was effected. 2 

Resection of the ends of the bones, first brought into notice by White, of Man- 
chester, in 1760, 3 and opposed by Brodie 4 as dangerous, and by Malgaigne 
regarded as generally useless or unnecessary, has still been practised a great 
number of times, with more or less success. It is especially applicable to super- 
ficial bones, and in cases where the bones overlap. Its value is now sufficiently 
demonstrated, except, perhaps, in the case of the femur. Eoux practised resec- 
tion in one instance, and then managed to engage the point of one of the frag- 
ments in the medullary canal of the other. I have succeeded in doing the 
same. 

White, of Manchester, Henry Cline, of London, Hewson, Barton, and Norris, 5 
of Philadelphia, have applied caustics directly to the ends of the fragments, after 
having exposed them by a free incision. 6 Petit applied the actual cautery. 7 

Tying the fragments together by means of metallic ligatures after a recent 
fracture is as old as the days of Hippocrates; but in 1805 Horeau adopted the 
same procedure in a case of ununited fracture ; 8 since which date it has been 
practised successfully by many surgeons. My own experience confirms the 
value of the method, especially when the fragments overlap. 

E. S. Gaillard, of Louisville, Ky., proposes to secure the fragments in place 
by means of a metallic pin. The instrument which he employs is composed of a 

1 Brodie, Lond. Med. Gaz., July, 1834. - Norris, loc. cit., p. 48. 

3 Diet, de Med., vol. xxiii. p. 503. 

* Brodie, New York Journ., vol. viii. 1st ser., p. 133. 

5 Norris. loc. cit., p. 49. 6 Ibid. " Ibid. 

8 Norris, loc. cit., p. 49. 

6 



82 DELAYED AND NON-UNION OF BROKEN BONES. 

steel shaft with a handle, a silver sheath, and a brass nut. For a broken femur 
the shaft is six inches long, its lower extremity being constructed like a gimlet, 
while two and a half inches of its upper extremity are cut for a male screw, 
being intended to carry the brass nut. The sheath is three inches long. 
Through an incision made over the seat of fracture, the sheath, detached from 
the shaft, is carried down to the bone. The shaft is then passed through the 
sheath, and made to penetrate and transfix the two fragments ; as soon as this 
is accomplished, the nut is turned down firmly upon the top of the sheath, and 
apposition of the fragments is thus secured. The whole instrument is permitted 
to remain until bony union is effected. 1 

Fitzgerald, of Melbourne, has practised successfully the injection of five to ten 

Fig. 28. 




Gaillard's instrument for ununited fractures. 

minims of glacial acetic acid between the fragments. It causes at first a sharp 
pain, and he thinks it accomplishes its beneficial results by causing a resolution 
and absorption of the interposed fibrinous, cartilaginous materials and encour- 
aging the substitution of bone. 2 

Finally, having thus brought rapidly before us all of the various 
modes of treatment which have been suggested and practised for non- 
union of broken bones, we are prepared to affirm the following conclu- 
sions, or summary of what has been our own practice, and of what we 
believe ought to be the general course of procedure in these cases : 

1. Improve the condition of the general system. 

2. Remove as far as possible the local impediments, such as a separa- 
tion of the fragments, local paralysis, local scurvy resulting from long 
exclusion from light and air, congestions, etc. 

3. Increase the action of the tissues immediately adjacent to the 
fracture, upon which tissues, rather than upon the bone, the formation 
of callus depends. This may be accomplished by frictions, and violent 
flexions of the limb at the seat of fracture : possibly in some measure by 
the application of vesicants or of other stimulants to the skin itself. 

4. Employ again compression and rest for a period of from two to four 
or eight weeks. 

5. Resort to the method recommended by Brainard, or to some of its 
modifications, to interfragmentary injections, etc. 

6. If in the lower extremity, allow the patient to walk about wath the 
fragments well supported. 

[7. If simple measures fail, resort to the operation of wiring the frag- 
ments, with antiseptic precautions.] 

Where these measures have failed, after a fair trial, we should cease 
to hope for success from operative measures, and subsequently rely only 

1 E. S. GaiHard, New York Journ. Med., Nov. 1865. 

2 Boston Med. and Surg. Journ., Aug. 15, 1878, from Medical Press and Circular. 



BENDING OF THE LONG BONES. 83 

upon retentive apparatus, under the continued use of which consolidation 
is sometimes effected. 

More precise rules of procedure will be given hereafter in connection 
with the various fractures. 



CHAPTEK VIII. 

INCOMPLETE FRACTUKES. 

BENDING, PARTIAL FRACTURES, AND FISSURES OF THE LONG EONES. 

§ 1. Bending of the Long Bones. 

Strictly speaking, no bone can be much bent without being also 
more or less broken, and that whether it immediately or spontaneously 
resumes its position or not ; for, if the bending and straightening of the 
bone be repeated a sufficient number of times, the yielding of the fibres 
will become apparent, and at length the separation will be complete. 
The first of this series of flexions was quite as much responsible for this 
result as the last, and, no doubt, performed its share in the production 
of the complete fracture. There could be no impropriety, therefore, in 
speaking of a bending of the bones as a variety of incomplete fractures. 
They have been called, not inappropriately, interperiosteal fractures, 
since in these cases the periosteum is not broken. 

M. Blandin thinks that the outer and semicartilaginous laminae of the bone 
also do not break, while the deeper laminse suffer an actual disruption. 1 But it 
is quite as probable that in a majority of cases the true pathological condition 
is a compression of the bony fibres upon one side, and a corresponding expan- 
sion upon the opposite side, with only a slight interstitial fracture, too trivial 
to be easily recognized even in the dissection. Sometimes, as I have several 
times observed in my experiments on the bones of chickens, when the bones are 
small, and the bending is near the centre of the shaft, the whole of the laminse 
on the side of the retiring angle produced by the bending are doubled in, or 
indented toward the hollow of the bone, so that the fibres on the side of the 
salient angle are not even stretched, and much less broken. In such cases the 
interstitial disruption, if it exist at all — and I think it does — first takes place in 
the deeper layers of the retiring angle. I might, therefore, feel justified in 
continuing to call these cases partial fractures, or, perhaps, interstitial fractures ; 
but I believe that the whole subject will be rendered more intelligible if I call 
them simply bending of the bones, as distinguished from those other and more 
palpably partial fractures of which I shall speak presently. 

Bending, with an Immediate and Spontaneous Restoration of the Bone 
to its Original Form. 

The possibility of this accident, to which, however, surgical writers 
have hitherto made no distinct allusion, is rendered certain by the fol- 
lowing experiments : 

1 Markham's Obs. on the Surg. Practice of Paris, London Med.-Chir. Rev., vol. xxxiv. 
p. 473, 1841. 



84 INCOMPLETE FRACTURES. 

Experiment I.— July 16, 1857. I bent the tibia of a Shanghai chicken, 
four weeks old, at about the middle of the bone. It was bent to an angle of 
quite twenty-five degrees, but it was not felt or heard to break. It immediately 
and spontaneously resumed the straight position. July 18, two days after the 
bending, I dissected the limb, and found no trace of the injury, either within or 
without the bone, unless I except a very minute blood-clot in the centre of the 
shaft. 

Experiment II. — I bent the leg of a chicken, four weeks old, at the same 
point and to the same degree. It immediately resumed the straight position. 
Dissection after two days: Nothing abnormal except a small blood-clot in the 
centre of the bone, and a slight disorganization of the medulla. 

Experiments III. and IV. — Bent both legs of a chicken, four weeks old, at 
the same point and in the same manner. They immediately resumed their 
positions. Dissection after two days : No lesions or morbid appearances which I 
could detect. 

Experiments V. and VI. — Bent both wings of a chicken four weeks old, 
bent the right wing to an angle of thirty-five degrees. I did not feel them 
break. Both resumed their positions spontaneously. Dissection after two days : 
No lesions or other morbid appearances. 

Experiment VII.— July 16, 1857, I bent the leg of a Shanghai chicken, five 
weeks old, below the knee and about the middle of the bone. It was bent to an 
angle of about twenty-five degrees, but the bone was not felt or heard to break. 
It immediately and spontaneously resumed the straight position. July 20, four 
days after the bending, I dissected the leg, but could not discover any trace of 
the injury, except that there was a very minute ossific deposit in the centre of 
the bone at the point at which I suppose it to have been bent. 

Experiment VIII. — July 16, 1857, I bent the right leg of a Shanghai 
chicken, five weeks old, at the same point as in the first experiment, and to the 
same extent. The bone did not seem to break, but it immediately and spon- 
taneously resumed the straight position. Dissection after four days: Nothing 
appeared to indicate the seat of the bending, except a small clot of blood in the 
centre of the shaft. 

Experiment IX. — Bent the leg of a chicken, six weeks old, in the same 
manner and to the same degree as in the other examples. It resumed its posi- 
tion spontaneously. Dissection after ten days : No evidence of injury of any 
kind ; the bone being sound and straight. 

These experiments were made in connection with others to which more 
especial reference will hereafter be made. They are selected, and constitute 
the whole number of those in which I did not feel the bone break or crack 
under my fingers. In every instance the bone sprung back immediately and 
spontaneously to its natural form. In no instance could I afterward discover 
any trace of lesion or sign indicating the point at which the bone had been bent 
before dissection, nor did dissection itself disclose anything but the most incon- 
siderable marks, and that in but three examples. 

I infer, therefore, not forgetting the caution with which the conclu- 
sions from all such experiments ought to be applied to simila'r accidents 
upon the human skeleton, that whenever the bones of healthy infants 
have been slightly bent and not broken, they will, probably, in most 
cases, unless prevented by causes foreign to the bones themselves, spon- 
taneously and immediately resume their position, and that no sign will 
remain to indicate that a bending has occurred. The accident will not 
be recognized, and, as a further inference, this bending does not belong 
to that class of cases of which I shall next speak. 

Bending, ivithout Immediate and Spontaneous Restoration of the Bone 
to its Original Form. 

" Dethleef, believing that he had broken the two bones of the legs of 
a dog, found the fibula bent without a fracture. Similar results were 



BENDING OF THE LONG BONES. 



85 



Fig. 29. 



obtained by Duhamel upon a lamb ; by Troja upon a pigeon ; and I have 
myself twice succeeded in bending the fibula while breaking the tibia. 
The possibility of simple curvature is then not contestable " (the writer 
means to say that the possibility of a simple curvature remaining perma- 
nently bent is not contestable), "but we must observe that they have 
never been obtained except upon young animals, and that they have 
been unable to maintain themselves permanently except through the aid 
of a fracture and displacement of a neighboring bone ; and there is a 
wide difference between these and those pretended . curvatures whieh 
some believe they have seen in man, in which the curved bone maintains 
itself, and resists perfect reduction until the fracture is complete." l 

In this single paragraph Malgaigne seems to have given a fair 
summary of the testimony upon this point. With the exception of these 
and a few other similar examples, some of which I think I have observed 
myself, where one of the bones of the forearm has been broken and the 
other bent, I know of no well-attested cases of a permanent bending ; 
using the term bending in a sense distinguished from a partial fracture. 

If, in numerous cases mentioned by surgical writers, there has seemed to be 
probable evidence that the permanent bending was unaccompanied with frac- 
ture, there has always been wanting, so far as I know, the 
positive evidence of dissection. The example of partial fracture 
mentioned by Fergusson, and represented by a drawing, is 
described as having also, "toward the lower extremity, a slight 
indentation and curve." 3 This was the radius of a child ; but 
how long the child survived the accident, and what was the 
condition of the ulna, we are not informed. The observations 
made by Jurine, of Geneva, in Switzerland," by Barton 4 and 
Norris, 5 of Philadelphia, all fail to furnish any such conclusive 
evidence of the correctness of their own views. Norris says 
that " Thierry, of Bordeaux, Martin, and Chevalier, had all met 
with and published cases of this kind prior to the appearance 
of Jurine's paper (in 1810), the former of whom asserts that 
Haller, in experimenting upon the subject, had been able satis- 
factorily to produce the same accident in young animals." For 
myself, I cannot say how much confidence we ought to place 
in these assertions of Thierry, Martin, and Chevalier, having 
never seen the papers referred to ; but since Dr. Norris has 
neglected to inform us whether any dissections were ever 
made, we shall not be expected to regard their testimony as 
conclusive. 

With the qualifications now made, Gibson was more nearly 
right when he said, "Dupuytren and Dr. John Rhea Barton 
have each furnished accounts of bent bones. There are no such 
injuries, however, in my opinion ; such cases being, in reality, partial fractures 
from which deformities result, upon the same principle that a piece of tough 
wood, like oak or hickory, if broken half through, may be inclined to one side 
and shortened, although still held together by interlocking of fibres. Many 
specimens in my cabinet, and in the Wistar Museum, attest the accuracy of this 
assertion." 

In my own experiments upon the chicken, the bones uniformly 
resumed their original position as soon as the restraining force was 




Case mentioned 
by Fergusson. 



1 Traite des Frac, etc., par L F. Malgaigne, torn. i. p. 48. 

2 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208. 

3 Journ. de Corvisart et Boyer, torn. xx. p. 278, etc. 

4 Phila. Med. Kecorder, 1821. 5 Phila. Med. Journ., vol. xxix. p. 233, 1842. 



8b INCOMPLETE FRACTURES. 

removed, unless a fracture occurred, and this notwithstanding the bones 
were bent quite abruptly and to an angle of twenty-five degrees. Cer- 
tainly, if the bones of children may be bent during life and be made to 
retain this position without a fracture, then the same thing might be 
done upon the bones of children recently dead, and, by successful 
experiments, this long-agitated question might be easily and forever put 
to rest. 

It will be understood that our observations are confined to the long 
bones. That the flat bones, and especially the bones of the cranium, in 
childhood, may be indented by blows, and remain in this condition, is 
undeniable. Scultetus says he had seen " the skull pressed down in 
children, without a fracture, so that those who touch or look upon it can 
perceive a small pit," and it has been mentioned by many writers since, 
and perhaps before his day. I have myself published two examples. 

§ 2. Partial Fracture of the Long Bones. 

Partial Fracture with Immediate and Spontaneous Restoration of the 
Bone to its Original Form. 

I have not noticed this variety of accident in any other bone except 
the clavicle, yet it is not improbable that it happens occasionally, and 
perhaps quite as often, in other long bones, but that its existence is not 
elsewhere so easily recognized. According to Poinsot, M. Demons has 
seen a similar case in the humerus of a newly born infant. 

Of one hundred and fifty-seven fractures of the clavicle recorded by 
me, thirty-four were partial fractures ; and of these at least eleven were 
spontaneously and immediately restored to their natural axes. 

In explanation of the fact that hospital surgeons have not observed so large 
a proportion of partial fractures of the clavicle, it must be stated that most of 
these cases of partial fracture were drawn from private practice. Accidents of 
this class may be often met with in private practice and in dispensaries, but 
they are seldom found in hospitals. 

In fourteen experiments which I have made upon the bones of 
chickens, a partial fracture, with immediate and spontaneous restoration, 
has occurred but once. In nine of these cases the bones were only bent, 
and in five they were partially broken ; an immediate restoration has 
occurred, therefore, in one case out of five of partial fractures ; while 
in my recorded examples of partial fracture of the clavicle it has been 
noticed about once in every four or five cases. The following is the 
experiment to which I have referred : 

I produced a partial fracture of the tibia in a chicken six weeks old. 
The fracture was near the middle of the bone. It was felt to break 
under my finger ; but, on removing the pressure, it immediately and 
spontaneously resumed the straight position. The limb was dissected on 
the tenth day. The line of the axis of the bone was perfect, but on the 
fractured side was a node-like enlargement, sufficient to be distinctly felt 
and seen before the soft parts were removed. 



PARTIAL FRACTURE OF THE LONG BONES. BY 

Pathology. — In no case, except in my single experiment upon the 
bone of a chicken, has the actual condition been determined by dissec- 
tion, and if any question has existed heretofore as to the possibility ot 
an immediate and spontaneous restoration after a partial fracture, this 
experiment ought to decide it in the affirmative ; but then the first nine 
experiments already quoted have shown that a mere bending with imme- 
diate restoration leaves no such traces or signs as have been described as 
following these accidents. We have, therefore, the negative argument 
that, since a bending with restoration leaves no signs, the examples, 
reported by myself and others as having occurred, and as having been 
followed by a node-like swelling, etc., must have been partial fractures. 
Moreover, in one of the cases of immediate restoration reported by 
Blandin, there was a feeble crepitus ; and in another, the subsequent 
displacement proved the correctness of his diagnosis. The same has been 
noticed by myself in several examples. 

No writer seems to have given any special attention to the form of fracture 
now under consideration, although its existence appears to have been occasion- 
ally recognized. In the case reported by Camper, in 1765, of a partial fracture 
of the tibia, the bone had regained its natural form, but whether immediately 
after the accident occurred, or at a later period, I am not able to learn. 1 Jurine, 
Gulliver, and others, have noticed a gradual straightening of the bone after a 
partial fracture, so that its complete restoration has been accomplished after 
several weeks or months ; but this, although partly due to the same cause which 
produces occasionally an immediate restoration, namely, its elasticity, is in part 
also due to other causes, and will be more properly considered under the next- 
division of partial fractures. 

Says Malgaigne: " Finally, at other times the fracture takes place without 
opening and without curvature ; the only sign which one can recognize is a 
yielding of the bone under the pressure of the finger at the point of fracture ; 
yet upon the living subject we may see the same symptom pertain to complete 
and simple fractures without displacement." 2 

In the following report of one of M. Blandin's clinics the accident is described 
a little more distinctly : " In some cases of fracture of the clavicle occurring 
about the middle of the bone in young subjects, displacement of the fragments 
does not immediately take place, thus giving rise to a risk of an error in diag- 
nosis, by which the ultimate probability of a cure is diminished. A lad, seven- 
teen years of age, was recently admitted into the Hotel Dieu, under the care of 
M. Blandin, having, a few days previously, fallen upon one of his comrades 
while playing with him, when he instantly experienced pain and a cracking sen- 
sation about the middle of the left clavicle, where there soon formed a tumor, 
which, increasing, induced him to enter the hospital. On examination, the 
swelling was found to occupy the middle of the clavicle ; it was about as large 
as half a hen's-egg, ovoid in shape, well circumscribed, colorless, and hard, but 
sensible to pressure. There was not any deformity of the shoulders, nor any 
abnormal modification of the axis of the bone, to indicate the existence of a frac- 
ture; and although the different movements of the arm caused pain in the 
shoulder, yet they could be made without much difficulty. 

" The symptoms in this case would lead to the belief that it was a case of 
simple periostitis, caused by external violence ; but M. Blandin at once decided 
that there existed a fracture of the bone, having seen a similar case previously 
at the Hopital Beaujon, where the tumor was treated as traumatic periostitis, the 
patient merely carrying his arm in a sling, until, by a sudden movement of the 
limb, displacement of the fragments was produced, and clearly demonstrated the 
existence of a fracture. A second case occurring soon afterward, M. Blandin 
profited by the experience gained from the preceding, and by moving the frag- 

1 Essays and. Obs. Phys. and Lit. of Soc. of Edinburgh, vol. iii. p. 527. 
- Op. cit.,tom. i.p. 70. 



88 INCOMPLETE FRACTURES. 

ments of the broken clavicle on each other, obtained motion and crepitus. Still 
these indications were not so clear that M. Marjolin could diagnosticate a frac- 
ture ; he was of opinion that the case was one of exostosis, probably syphilitic, 
and the crepitus, he believed, depended on an erosion of the osseous surface. 
In conseqaence, the patience was left to himself, until a movement of the arm 
gave proof of the fracture by the displacement of the broken portions of the 
bones. 

" Two other cases occurring in young subjects have been admitted since in the 
Hotel Dieu, under the care of M. Blandin, one of whom was purposely left with- 
out surgical assistance, while Desault's bandage was applied to the other. The 
former soon showed evidence of consecutive displacement; the latter was cured 
without any deformity following. The surgeon may diagnosticate a fracture 
without displacement of the middle portion of the clavicle, when a circumscribed 
tumor forms in that part of young subjects, consecutive on a fall on the shoulder, 
and motion of the fragments, with crepitus, can be detected, there not being any 
syphilitic taint in the constitution." 1 

The following examples, which have come under my own observation, will 
illustrate more completely the usual history and symptoms of these cases: 

A. B., aged three years, fell from a sofa upon the floor, striking, it is thought, 
on her right shoulder. Two days after this, she fell again, and then, for the first 
time, Mr. B. noticed the deformity. She was brought to me three days after the 
second fall. There existed, then, a round, smooth projection at the outer end 
of the middle third of the clavicle. It felt hard, like bone. The line of the 
clavicle was not changed. I advised a handkerchief sling, simply to steady and 
support the arm. Seven months after the accident, she fell sick and died. The 
projection continued at the time of death, only slightly diminished. 

H. S., aged six years, was thrown from a horse, partially breaking his left 
clavicle, near its middle. The projection in front was for several days very 
apparent. The bone did not seem to be out of line. Five years after the acci- 
dent, I examined the lad, and could not find any trace of the original injury. 

Mrs. T. C. brought to me her infant child, then but two weeks old. Upon 
the left clavicle, at a point a little nearer the acromion process than the ster- 
num, was an oblong swelling, three-quarters of an inch in length, smooth and 
hard like callus ; the skin was not reddened, nor tender. There was no motion 
or crepitus, and the line of the axis of the bone was perfect. The mother, who 
had been put to bed by a midwife, thinks the injury occurred in the act of birth, 
although she did not notice the swelling until a week after. Nearly one month 
later, I found no change in the condition of the bone ; the hard lump remained, 
but it was still entirely free from tenderness. 

An infant boy, three years old, fell from the hands of the nurse. The child 
cried, but the point of injury was not detected until the third or fourth day, 
although the mother examined the shoulders and neck carefully at the time. 
She is quite certain that if any swelling or discoloration had been present, she 
would have seen it then, or on the subsequent days, while washing and dressing 
the child. When first seen it was very distinct, but not so large as at present. 
Seven days later the child was brought to me. A little to the sternal side of the 
middle of the right clavicle there was an oblong node-like swelling, of the size 
of the half of a pigeon's egg, hard, smooth, and feeling like bone ; there was no 
discoloration or swelling of the integuments ; no crepitus or motion; the line of 
the clavicle seemed nearly or quite unchanged. 

Diagnosis. — The diagnosis will depend somewhat upon the history of 
the accident as well as upon the present symptoms. In no instance, 
where I could ascertain the cause, have I known an incomplete fracture 
of this variety produced by any other than an indirect blow ; and where 
the clavicle has been the seat of the fracture, the counter-blow has been 
received upon the end of the shoulder. The fact possesses, therefore, 

1 Amer, Journ. Med. Sci., vol. xxxi. p. 473, from Journ. de Med. et Chirurg. Prat. 
July, 1842. 



PARTIAL FRACTURE OF THE LONG BONES. 89 

equal significance in its relation to either of the varieties of partial frac- 
ture ; but in the case of a partial fracture with a permanent curvature, 
the diagnosis would be complete without the history, while in this case 
it might not be, and a knowledge of the manner in which the accident 
occurred would, therefore, be of great importance. The signs, then, 
after a knowledge of the fact that a blow has been received upon the 
shoulder, are a node-like swelling upon the anterior or upper face of the 
clavicle, generally in its middle third, this swelling being hard, smooth, 
oblong ; the skin only slightly or not at all swollen or tender, and in no 
way discolored, as it would have been had the swelling upon the bone 
been the result of a direct blow ; and the line of the axis of the bone 
being unchanged. 

I have occasionally detected motion and crepitus at the point of injury, and 
we have seen that Blandin was able to detect both in one instance ; but it has 
never occurred to me to see the swelling upon the bone until two or three days 
after the injury was received. We are not very likely, therefore, to recognize 
this accident immediately after its occurrence. 

Treatment. — In the case of the clavicle, neither bandages, slings, 
compresses, nor lotions can be of much service. Yet no harm can arise 
from employing a simple sling and roller to confine the arm ; and it is 
always proper to enjoin some degree of care in using the arm of the 
injured side. The consolidation will be speedily accomplished, and after 
a time the ensheathing callus will wholly disappear. If a similar acci- 
dent should occur in any other of the long bones, as retentive and pre- 
cautionary means, splints ought to be applied, at least for a few days. 

Partial Fracture, ivithout Immediate and Spontaneous Restoration 
of the Bone to its Natural Form. 

The causes of this accident are the same as those which produce 
simple bending, or partial fracture with immediate and spontaneous 
restoration, from which latter they differ probably in the greater extent 
of the bony lesion. Perhaps, also, they differ sometimes in the peculiar 
form and degree of the denticulation at the seat of the fracture ; in con- 
sequence of which an antagonism of the fibres takes place, preventing 
a restoration of the bone to its original form. 

A r ery few surgeons have spoken of partial fracture in the clavicle, while 
Jurine, Syme, Liston, Miller, Norris, and many others, have declared that it is 
much more frequent in the bones of the forearm than elsewhere. This does not 
agree with my experience, according to which it occurs oftener in the clavicle 
than in the forearm ; a discrepancy which I cannot very well explain, except 
by supposing that in the case of the clavicle the accident has either been over- 
looked entirely or misapprehended. Blandin, who, we have seen, has reported 
five cases of partial fracture of the clavicle with immediate restoration, states 
distinctly that in two of these cases distinguished surgeons of the Hopital Beaujon 
and Hotel Dieu failed to recognize it. 

Says Turner: "The next I shall descend to is that of the clavicle or collar- 
bone, which I have found the most frequently overlooked, I think, of any other, 
till it has been sometimes too late to remedy, especially among the children of 
poor people; for, though they find these little ones to wince, scream, or cry, 
upon the taking off or putting on their clothes, yet, seeing that they suffer the 
handling of their wrists and arms, though it be with pain, they suspect only 



90 



INCOMPLETE FRACTURES, 



some sprain or wrench, that will go away of itself, without regarding anything 
further or looking out for help ; whereas, this fracture discovers itself as easily 



Fig. 30. 



Fig. 31. 




Uli.'MWiip 1 ' 

Partial fracture of the clavicle without spontaneous restoration- 
From nature ; taken three weeks after the accident. 



Partial fracture with- 
out restoration of the 
bone to its natural form. 



as most others. For not only the eye, in examining or 
taking a view of the part, may plainly perceive a bunch- 
ing out or protuberance of the bones when the neck is 
bared for that purpose, with a sinking down in the mid- 
dle or on one side thereof, which will be still more ob- 
vious on comparing it with its fellow on the other side; 
but when it is more obscure, and the bone, as it were, 
cracked only — a semi-fracture, as we say — yet, by press- 
ing hard upon the part, from one extremity to the other, 
you will find your patient crying out when you come 
upon the place ; and by your fingers, so examining, sometimes perceive a sinking 
further down, with a crackling of the bone itself." 1 

Erichsen, who regards all of these cases as mere bendings of the bones, re- 
marks that it " most commonly occurs in the long bones, especially the clavicle, 
the radius, and the femur." 2 He says, moreover, "Fracture of the clavicle in 
infants not unfrequently occurs, and is apt to be overlooked. The child, cries 
and suffers pain whenever the arm is moved. On examination, an irregularity, 
with some protuberance, will be felt about the centre of the bone." 3 The reader 
will not fail to recognize in these symptoms the incomplete fracture of which 
we are now speaking, although Erichsen evidently believes them to be examples 
of complete fracture. 

Pathology. — The following experiment will assist in the elucidation of 
this part of our subject : 

Experiment. — I bent the leg of a chicken five weeks old. It cracked under 
my fingers, and remained bent. Having waited a few seconds, and finding that 
it was not restored to position, I pressed upon it and made it straight. The 
chicken walked off without any limp. On the fourth day,, before dissection, the 
bone looked as if it was still bent; but, on removing the soft parts, the line of 
the axis of the bone was found to be straight. The areolar tissue under the 



1 Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 255. 

2 Science and Art of Surgery, Phila. ed., 1854, p. 180. 
a Op.cit.,p. 205. 



PARTIAL FRACTURE OF THE LONG BONES. 



91 



Fig. 



skin was infiltrated with lymph, which was most abundant near the fracture, 
and gradually diminished toward each extremity of the limb. This effusion was 
confined almost entirely to the front of the limb, or to that side which had 
been broken, and constituted the greater part of the enlarge- 
ment, which I had noticed before the dissection was com- 
menced, and which then felt like bone. On the front of the 
bone, also, underneath the periosteum, there was a loose, 
honeycomb deposit of ensheathing callus, about one line in 
thickness, and extending upward and downward about half 
an inch. This callus surrounded the bone in three-fourths 
of its circumference ; but there was no callus on its posterior 
surface. It was also deficient exactly along the line of frac- 
ture, in front and on the sides, in consequence of which an 
oblique groove remained, indicating the seat of the fracture. 

In three other experiments, the particulars of which are 
detailed in the earlier editions of this book, similar results 
were obtained. 

So early as the year 1673, a dissection made by Glaser 
demonstrated incontestably the existence of partial fractures 
in the shaft, and in the direction of the diameter of long 
bones. 1 Camper, in 1765, again described a specimen which 
he had seen ; 2 and Bonn, in 1783, added a third positive ob- 
servation. 3 

M. Gimele is, therefore, in error when he ascribes to Cam- 
paignac the credit of having first proved by dissection their 
existence, in a paper communicated to the Academy of 
Medicine at Paris, in 1826. Campaignac, however, seems to 
have been the first who described very particularly the con- 
dition of this fracture. He has recorded the history and 
dissection of two cases, one of which occurred in the fibula, 
and one in the tibia. The first of these cases was a girl 
twelve years old, who survived the accident just eight weeks. 
The fracture had occurred near the middle of the bone, and 
upon the interior and internal side; in which direction, 
resting against the tibia, the bone was found inclined. " The 
bony fibres had been broken at different lengths, almost 
exactly like what takes place in the branch of a tree which 
has been partially broken ; and, as we see sometimes in this 
latter case, the bundles of splintered bony fibres abutted 
upon themselves, and did not take their places when w r e 
endeavored to restore them ; so the abnormal angle which the fibula represented 
could not be effaced, the ends of the divided fasciculi not restoring themselves 
to their respective places. This disposition might be especially seen toward the 
anterior part of the internal face, where a packet of fibres, coming from below, 
was braced against the upper lip of the division, which it thus held open. This 
opening at first made me think that the fragments could not have been well 
consolidated, but I assured myself that it was, and the fact was subsequently 
confirmed by the Academy of Medicine ; all the points which were in contact 
were found intimately united." 4 

Diagnosis. — The diagnosis is not difficult. The distortion indicates 
sufficiently the existence of a fracture, while the complete absence of 
crepitus in nearly all cases, and of either overlapping or lateral displace- 
ment, must generally, especially where the accident has occurred in a 
child, sufficiently indicate that the fracture is incomplete. It will assist 



Partial fracture 
after union is con- 
summated. 



1 Malgaigne, op. cit., p. 44, from Th. Boneti Sepulchretum, 1700, torn. iii. p. 424. 
9 Essays and Obs. Phys. and Lit. of Soe. of Edinburgh, 1771, vol. iii. p. 537. 

3 Malgaigne. op. cit., p. 44, from Descript. Thes. Ossium. Morb. Hoviani, 1783. 

4 Des Fractures Incompletes et des Fractures Longitudinales des Os des Membres; par 
J. A. J. Campaignac. Paris, 1829, pp. 9, 10. 



V% INCOMPLETE FRACTURES. 

the diagnosis, also, to notice that these accidents are almost confined to 
the middle third of the long bones ; and they are produced usually by a 
bending of the bones, the forces operating upon the extremities, and not 
directly upon the point which is broken. In complete fractures the pre- 
ternatural mobility is so constant a sign as to be regarded as diagnostic 
where there is almost always a great degree of immobility at the seat of 
fracture. The angle made by the projecting extremities is usually rather 
gentle and smooth; at other times it is abrupt, indicating a greater 
amount of fracture, or that the outer fibres are broken more irregularly. 
The power of using the limb is generally sensibly impaired, but not com- 
pletely lost. 

Treatment. — Jurine, Murat, Campaignac, Gulliver, Malgaigne, with 
some others, have noticed the fact that it is often difficult, and some- 
times quite impossible, to restore these bones to position ; a circumstance 
which they have justly ascribed to that condition of the fragments de- 
scribed by Campaignac. The broken extremities of the fasciculi become 
braced against each other, and effectually resist all efforts to straighten 
the bone ; unless, indeed, so much force is used as to render the fracture 
complete ; a result which, if it should chance to happen, need not occa- 
sion any alarm, since, while it enables us at once to restore the bone to 
line, it does not much increase the danger of lateral displacement and 
overlapping. That the fracture has become complete we may know by 
a sudden sensation of cracking, by the increased mobility, and by the 
crepitus, which is now easily developed. 

But we need not, on the other hand, be over-anxious to straighten the 
bone completely, since experience has shown that after the lapse of a few 
weeks or months the natural form is usually restored spontaneously. I 
am not now speaking of those cases in which the restoration occurs imme- 
diately, in which it is probable that the splintered fibres offer no resist- 
ance to the restoration ; but only of those in which the bone straightens 
so gradually as to induce a belief that the broken ends are the cause of 
the resistance. In a case mentioned by Gulliver, it required about four 
weeks' time to render the bones of the forearm perfectly straight ; and 
in one case mentioned by Jurine, at the end of six months it was " diffi- 
cult to say which arm had been broken, and at the end of one year it 
was impossible." 

Jurine attributes this restoration to "muscular action, or more especially to 
the reaction of the compressed bony plates;" but while it is easy to understand 
how the reaction of the compressed fibres may accomplish the gradual restora- 
tion, I am unable to understand in what manner muscular action contributes to 
this result, since most of the muscles attached to the long bones operate so much 
more energetically in the direction of their axes than in the direction of their 
diameters. Indeed, we have often seen these bones bent after complete fractures, 
and before the union was consummated, by muscular action alone. 

I repeat, then, that the gradual restoration of these bones is due to the 
same circumstance which produces at other times an immediate restora- 
tion, namely, the elasticity of the unbroken fibres, but which elasticity, 
in this latter instance, is, for a time, effectually resisted by the bracing 
of the broken fibres. At length, however, in consequence of the gradual 
absorption of the broken ends, the resistance is removed, and the bone 



FISSURES. 93 

becomes straight. If this absorption refuses to take place, and the fibres 
continue pressed forcibly against each other, as in the case described by 
Campaignac, then the bone remains permanently bent. 

Having straightened the bone as far as is practicable, it only remains 
to secure the fragments in place by suitable bandages or splints. If the 
restoration is incomplete, these means may assist the efforts of nature in 
accomplishing a gradual restoration. It is scarcely necessary to say that 
extension and eounter : extension avail nothing in partial fractures. 

§ 3. Fissures. 

The fissures constitute the second principal form of incomplete frac- 
tures, or those in which the fracture is accompanied with no appreciable 
bending, which occur almost exclusively in inflexible bones, such as the 
compact bones of adults, and more often in the direction of their axes 
than of their diameters. They are complete so far as they extend, but 
they do not completely sever the bone so as to form two distinct frag- 
ments. They have been most frequently observed in the flat bones, such 
as the bones of the skull, and in the upper bones of the face ; occasion- 
ally in the long bones, both in their diaphyses and epiphyses, and rarely 
in the short bones. 

M. Gariel has reported, in the Bulletins de la Societe Anat., for 1835, a case of 
fissure of the inferior maxilla, occurring in a lad sixteen or eighteen years old. 
Palletta found a fissure extending partly through the third dorsal vertebra, in a 
man who had fallen upon his back eleven days before ; and M. Lisfranc has 
mentioned a remarkable case of fissure and partial fracture, with bending of five 
ribs in the same person. 1 In the skeleton of an Indian the scapula was found 
broken nearly transversely, the fracture commencing upon the posterior margin 
at a point about three-quarters of an inch below the spine, and extending across 
the body of the bone one inch and three-quarters, in a direction inclining a little 
upward, being irregularly denticulate and without comminution. The fragments 
were in exact apposition, and, throughout most of their extent, in immediate 
contact. They were, however, not consolidated at any point, but upon either 
side of the fissure there was a ridge of ensheathing callus, of from one to three 
or four lines in breadth, and of half a line or less in thickness along the broken 
margin, from which point it subsided gradually to the level of the sound bone. 

M. Voillemier found the head of the humerus penetrated by two or three 
fissures ; 2 and M. Campaignac reports the case of a lad ten or twelve years old 
in whom the humerus was found, after amputation, fissured from the insertion 
of the deltoid to near the condyles, extending through the entire thickness of 
the bone, and the edges of the fissure so much separated toward its lower ex- 
tremity as to admit the blade of a knife. 3 Chaussier has related a case in which 
a criminal, who died soon after having submitted to the torture, was found to 
have a nearly longitudinal fissure of the radius in its upper fourth, and which 
penetrated half-way through the thickness of the bone. 4 Gulliver saw a fissure 
in the pelvis of an infant. 5 Malgaigne has seen two specimens of this fracture 
in the iliac bones, both of which belonged, as he thinks, to adults; in one, the 
fissure was limited to the internal table ; 6 and in the case of the lad reported by 
Gariel, as having a fissure of the inferior maxilla, there was also found a fissure 
of the left ilium, but which was limited to the outer table. 7 M. J. Cloquet has 

1 Des Fract. Incomplet. et des Fissures, par J. A J. Campaignac, 1829, p. 20. 

2 Malgaigne, op. cit., p. 35. 

3 Campaignac, Des Fract. Incomplet., etc., p. 24. 

4 Med. Legale, p. 447 et seq. 5 Gazette Med., p. 1835, p. 472. 

6 Malgaigne, op. cit., p. 34. ' Bulletins dela Soc. Anat., 1835, p. 24. 



94 INCOMPLETE FRACTURES. 

mentioned a case of fissure of the shaft of the femur passing through the con- 
dyles and extending upward to near the middle of the bone, produced by a 
bullet, which had completely traversed the bone from behind forward, a little 
above the condyles. 1 

A fissure of the neck of the femur is reported by Dr. Jackson, of Boston. 
The fracture commences anteriorly just above, but very near to the insertion of 
the capsular ligament, runs along the insertion for about an inch, and then 
extends directly upward to the margin of the head of the bone; from this last 
point it crosses the upper surface of the neck almost in a straight line, and at a 
little distance from the margin of the head, but afterward approaches very 
closely to this margin posteriorly ; it then turns downward and obliquely for- 
ward, and stops at a point about halfway between the small trochanter and the 
head of the femur, and two-thirds of an inch or more anteriorly to the line of 
this trochanter. The fracture then involves about three-fourths of the neck of 
the bone; the inner anterior portion only being spared. There is considerable 
motion between the neck and the shaft, and the fracture could undoubtedly be 
completed without the application of any extraordinary force. There was, also, 
a transverse fracture of the same femur midway, with a split extending upward 
nearly to the neck of the bone. The femur is perfectly healthy in structure, 
and no changes are observable in the bone about the fracture." 2 In Dr. Mutter's 
collection is a specimen of fissure of the trochanter major. There is an example 
of a fissure in a patella belonging to the museum of the Edinburgh College of 
Surgeons, the fissure traversing its articular face only. 3 

The first example of a fissure of the tibia is recorded by Corn. Stalpart Van- 
der-Wiel, in 1867; and indeed this is, according to Campaignac, the first exact 
observation of this species of fracture which our science possesses, although its 
existence had been recognized by the most ancient authors. A servant had 
been kicked by a horse, and after a time, pain continuing in the limb, his sur- 
geon, Dufoix, suspected a fissure of the tibia, and having cut down to the bone, 
a cure was soon effected. 4 

In the Dupuytren Museum, at Paris, there are two tibiae with linear fractures, 
one without history, and the other presented by MM. Marjolin and Kullier, 
"and which had been broken by a ball." 5 In the example related by Cam - 
paignac, a woman, having leaped from a second-story window, died immediately, 
and upon examination she was found to have three fissures in the upper portion 
of the left tibia, of which only one entered the articulation. 6 

Duverney saw a priest who had fallen and bruised the middle of his left leg, 
the swelling and pain consequent upon which were subdued after a few days. 
The patient believed himself cured, and acted accordingly. Suddenly, in the 
night, he was seized with an acute pain in the limb ; and on cutting down to the 
bone a bloody serum escaped from between it and the periosteum, and the bone 
was discovered to be fissured longitudinally. Subsequently the tibia was tre- 
phined, but the fissure did not reach the marrow. He recovered completely in 
less than two months. The same writer mentions another case, in which a 
soldier received the kick of a horse in the middle of his left leg, which was fol- 
lowed immediately by great pain, and subsequently by much inflammation, and 
even gangrene of the skin. The wound, however, cicatrized kindly, but after 
three months he was seized suddenly with a severe pain in the limb, and after 
the trial of many remedies, resort was finally had to the knife, when the tibia 
was seen to be discolored and cracked longitudinally. On the following day, 
the bone was opened over the course of the fissure with a chisel and mallet, and 
the patient was at once relieved by the escape of a yellowish and very offensive 
matter. At the next dressing the bone was opened more freely by several appli- 
cations of the trephine, and an abscess was exposed in the centre of the bone. 

1 These du Concours de Pathol. Externe, 1831, pi. xii. fig. 7. Also, Des Fract., etc., par 
Campaignac, U29, p. 19. 

2 Boston Med. and Surg. Journ., vol. lv. p. 351. See also Amer. Journ. Med. Sci. for 1857, 
p. 306, with engraving; and Bigelow on Hip-joint, p. 137. 

3 Malgaigne, op. cit., p. 35. 

4 Campaignac, op. cit., p. 17. 5 Malgaigne, op. cit.. p. 36. 
6 Campaignac, op. cit., p. 21. 



FISSURES. 95 

The patient finally recovered after about four months. 1 M. Campaignac saw 
also, at the Hopital la Charite, the tibia of a woman, set. thirty-eight years, upon 
which were found four fissures, the report of which case is accompanied with a 
woodcut illustration. 2 

Fissures may occur probably at all periods of life, but they are more 
frequently found in the bones of adults. 

Campaignac, however, mentions a fissure of the humerus in a child ten or 
twelve years old, and Gulliver has seen a fissure in the pelvis of an infant. 

Etiology. — Fissures may be occasioned by most of those causes which 
produce fractures in general, such as direct or indirect shocks ; but they 
are occasioned much more often by direct blows, especially when inflicted 
upon bones imperfectly covered by soft parts, such as the tibia. Bullets, 
having violently struck or penetrated the bone, have frequently occasioned 
fissures. Their course may be parallel with the axis of the bone, oblique, 
or transverse ; they are often multiple ; some merely enter the outer 
laminae, others open into the cellular tissue, and others still divide both 
surfaces of the bone through and through ; and, according as they pene- 
trate more or less deeply the bone, their lips will be found to be more or 
less separated. They frequently extend into the joint surfaces. 

Diagnosis. — The signs which indicate the existence of a fissure must, 
in a large majority of cases, be insufficient to determine fully the diag- 
nosis during the life of the patient. It is not probable that such fissures 
could ever be clearly made out by the touch alone, w T here the skin is not 
broken, since the pain, swelling, suppuration, etc., are only characteristic 
of inflammation of the bone or of its coverings, and might be equally 
present whether a fracture existed or not. In those rare cases only in 
which the flesh is torn off", and the surface of the bone is brought 
directly under the observation of the eye, will the diagnosis become 
certain. 

Treatment. — Fortunately, an error in judgment in this matter will 
not materially, if at all, prejudice the interests of the patient ; since, 
whatever may be the fact in other respects, if the bone, or its perios- 
teum, or its medullary tissue, is inflamed, and rest, with antiphlogistics, 
does not accomplish its speedy resolution, incisions and perforations 
become inevitable if we would give either safety or relief to the sufferer. 
Accordingly, in the inflammation and suppuration consequent upon these 
fractures, w~e have seen that it has been occasionally found necessary to 
lay open the soft tissues freely, and even to trephine the bone at one or 
more points. 

Fissures in Cartilage.— I have once met with a fissure in the thyroid 
cartilage, which constitutes, so far as I know, the only example upon 
record of a fissure in cartilage. 3 

1 Malgaigne, op. cit., p. 39, et seq. 2 Campaignac, op. eit., pp. 21, 21. 

3 Buffalo Med. Journ., vol. xiii., article entitled Fracture of the Thyroid Cartilage. 



96 FRACTURES OF THE NOSE, 



CHAPTEE IX. 

FRACTUEES OF THE NOSE. 
§ 1. Ossa Nasi. 

Of twenty-five cases of fracture of the ossa nasi only fourteen were 
seen by a surgeon in time to afford relief. From this fact we learn how 
frequently the nature of this accident is overlooked by the friends, and 
even by the surgeon, and the necessity of always instituting, in such 
cases, careful and thorough examinations. In some cases, where sur- 
geons were called in time, and a deformity remains, it is not improbable 
that the accident was not recognized. The rapidity with which swelling 
ensues after severe blows upon the nose, concealing at once the bones, 
and lifting the skin even above its natural level, explains these mistakes. 
The nose, also, is remarkably sensitive, and the patient is often exceed- 
ingly reluctant to submit to a thorough examination. It ought, however, 
not to be forgotten that the omission on the part of the surgeon to do his 
duty will not always be excused, even though the patient himself has 
protested against his interference, especially where an organ so promi- 
nent, and so important to the harmony of the face, is the subject of his 
neglect or mal-adjustment ; since the most trivial deviation from its orig- 
inal form or position, even to the extent of one or two lines, becomes a 
serious deformity. 

Causes. — When the ossa nasi are struck with considerable force, from 
before and from above, a transverse fracture occurs usually within from 
three to six lines of their lower and free margins, and the fragments are 
simply displaced backward ; if the blow is received partially upon one 
side, they are displaced more or less laterally. This is what will happen 
in a great majority of cases, as I have proved by examinations of the 
noses of those persons who have been the subjects of this accident, and 
by repeated experiments upon the recent subject. 

A more considerable force will break, generally, the ossa nasi trans- 
versely, and a little above their middle ; while, at the same time, the 
nasal processes of the superior maxillary bones may suffer slightly. 

With neither of these accidents is the cribriform plate of the ethmoid 
likely to be broken or disturbed. Indeed, in numerous experiments 
made upon the recent subject, and in which the force of the blow was 
directed backward and upward, breaking and comminuting the nasal 
bones above and below' their middle, with also the nasal processes of the 
superior maxillary bones, and the septum nasi, the cribriform plate of the 
ethmoid was, without an exception, uninjured. The exceeding tenuity 
and flexibility of the septum nasi at certain points prevents effectually 
the concussion from being communicated through it to the base of the 
brain. If, therefore, after these accidents, cerebral symptoms are occa- 
sionally present, as I have myself twice seen, they must be due rather 



OSSA NASI. \)( 

to the concussive effects of the blow upon the very summit of the nasal 
bones, where they rest immediately upon the nasal spine of the os frontis, 
or to some direct impression upon the skull itself. 

The amount of force requisite to break in the nasal bones, at their 
upper third, is very great ; no less, indeed, than is requisite to fracture 
the os frontis. If they do finally yield at this point, then no doubt the 
base of the skull must yield also. A force sufficient to break the base of 
the skull never fails to comminute and detach almost completely the 
septum nasi. Proceed in such a case as in a case of broken skull ; lay 
open the skin freely, and with appropriate instruments seek to elevate 
and remove, if necessary, the fragments. In such accidents our services 
will be of no value. 

Diagnosis. — Occasionally the bones are neither broken at their lower 
ends nor through their central diameters, but only at their lateral, ser- 
rated, or imbricated margins. This is rather a displacement, or disloca- 
tion, than a fracture. It is more likely to happen in childhood than in 
middle or old age. 

Thomas Kelley, aged four years, was kicked by a horse. Two hours afterward 
the nose and face were much swollen, and the fracture was overlooked. One 
year after the accident both nasal bones were depressed through nearly their 
whole length, especially in the lower halves. The right nasal process was also 
much depressed, and the right nostril obstructed. The lachrymal canals upon 
this side were closed. 

Sometimes the lower ends of the nasal bones are bent backward, or 
laterally, constituting a partial fracture. 

A lad, aged ten years, was hit by one of his mates accidentally w T ith his elbow, 
upon the left side of his nose. The lower end of the left os nasi was displaced 
laterally and backward, so that it rested under the lower end of the right os nasi. 
There did not appear to be any fracture beyond that which w r as inevitable by the 
mere separation of its serrated margins from the bone adjoining. The angle 
formed by the bone at the point where the bending had occurred was smooth 
and rounded, and not abrupt as in a complete fracture. With a steel instrument, 
introduced into the left nostril, I attempted to lift the bone to its place. The 
membrane was very sensitive, and the patient very restless under my repeated 
efforts. I pressed upward with considerable force, and succeeded at length in 
bringing the bone nearly into position. 

If there is more complete displacement, the upper ends are not usually 
forced backward, but rather a very little forward, from their articulations 
with the os frontis, and the bones then swing, as it were, upon the lower 
ends of the nasal spine, as upon a pivot. In this condition they are very 
firmly locked, and it requires considerable force, applied under their lower 
extremities, to restore them to place. In children, also, the nasal bones 
may be spread and flattened, the lateral margins not being depressed or 
displaced, but only the mesial line or arch forced back, so as to press 
aside the processes of the superior maxilla; which deformity may become 
permanent. 

A block of wood fell upon a child three weeks old, as she was lying in the 
cradle. The nature of the injury was not understood by the parents, and no 
surgeon was called. The ossa nasi are now, twelve years after the accident, 
much wider than is natural, and depressed; the nasal processes of the superior 
maxilla appearing to have been spread asunder. 



98 FRACTURES OF THE NOSE. 

Prognosis. — -As to the prognosis in these fractures, I can only say that 
either owing to the ignorance and carelessness of the patients themselves, 
who neglect to call a surgeon in time, or to the difficulty of diagnosis, or 
to the greater difficulty in maintaining an adjustment of the fragments, it 
has hitherto happened that, after the fracture of the ossa nasi, more or 
less deformity has usually remained. I have seen but a few which could 
be said to be perfectly restored. 

Benjamin Bell and others have spoken of tedious ulcers, polypi, necrosis, fis- 
tula lachrymalis, abscesses, impeded respiration, and impairment of the sense of 
smell and of speech, as circumstances apt to result from these injuries, and it is 
certain that such consequences have occasionally followed ; but they must gen- 
erally be regarded as accidents due to the state of the general system, and as 
having no connection with the fracture, except as this injury served to awaken 
certain vicious tendencies. 

Treatment. — The fragments are generally loose, and easily pressed 
back into place by the use of a proper instrument. A silver female 
catheter may answer well enough in a few instances, but it will more 
often fail. The diameter of the meatus at the point where the instrument 
must touch in order to make effective pressure upon the ossa nasi, is on 
the average not more than two lines ; and when the membrane which 
lines it is injured, it becomes quickly swollen, and reduces the breadth 
of the channel to a line or less. Under these circumstances, any instru- 
ment of the size of a female catheter could only be made to reach and 
press against the nasal process of the superior maxilla, which is too firm 
and unyielding to allow it to pass without the employment of unwarrant- 
able force. In this way it happens that the operator is occasionally 
surprised to find how much resistance is opposed to his efforts to lift the 
bones, and, after repeated unsuccessful attempts, the case is not unfre- 
quently given over. If, however, he had used a smaller instrument, he 
would have found almost no resistance whatever. A straight steel 
director, or sound, or sometimes even a much smaller instrument, if pos- 
sessing sufficient firmness, is more suitable than the catheter. For the 
same reason, also, one ought never to wrap the end of the instrument 
with a piece of cotton cloth, as some, without much consideration, have 
recommended. The facility with which these bones may be replaced, 
when a proper instrument is employed, is true only when the treatment 
is adopted immediately, or at most within a few days after the accident. 

Boyer, Malgaigne, and others have noticed the fact that these fractures are 
repaired with great rapidity. Hippocrates thought the union was generally 
complete in six days; and in a case of my own, the fragments were quite firmly 
united on the seventh day. Malgaigne states that repair is effected without the 
interposition of provisional callus, but " par premiere intention" Among the 
specimens illustrating fractures of the ossa nasi, in all over forty, in no instance 
has there been detected, after a careful examination, the slightest trace of pro- 
visional callus. 

It will not always be as easy to retain the fragments in place, as it is 
to replace them. The very swelling which takes place so promptly under 
the skin tends to depress the fragments, unsupported as they are by any 
counter- force ; a tendency which, possibly, is in some instances increased 



OSSA NASI. • 99 

by attempts on the part of the patient to clear his nostrils by snuffing 
and hawking. I have, in one instance, noticed very plainly a motion in 
the fragments when such efforts were made. To remedy this, none of 
the plans suggested possess much practical value. Few patients will 
consent to the introduction of pledgets of lint, or of stuffed bags, or, 
indeed, of anything else, sufficiently far up into the nostrils to answer 
any useful purpose. The membrane is too sensitive and too intolerant 
of irritants to enable us to have recourse generally to such methods. 
Then, too, it would require, on the part of the surgeon, more than 
ordinary tact to accomplish so nice and delicate an adjustment of the 
supports from below as these cases demand, where the slightest excess of 
pressure, or the least fault in the position of the compress, must defeat 
the purpose of the operator. 

If the attempt is made, push up in succession a number of small 
pledgets of sheet lint, smeared with simple cerate, to each one of which 
there has been attached a separate string, so arranged that their relative 
position may be recognized, and that they may at a suitable time be 
removed in the order of their introduction. 

The employment of canulas, as recommended by Boyer, B. Bell, and 
others, allows of the nostrils being stuffed without interfering materially 
with the breathing; a provision, however, which is quite unnecessary 
with a majority of persons, so long as there exists no impediment to the 
free admission of air through the fauces. 

Fig. 33. 




Mason's dressing. 



With nicely adjusted compresses of soft cotton or lint, and secured 
upon the outside of the nose with delicate strips of adhesive plaster or 
rollers, we shall be better able to prevent the fragments from becoming 
displaced outward than by moulds of wax, of lead, or of gutta-percha, 
under which it is impossible to see from hour to hour what is transpirino*. 



100 FRACTURES OF THE NOSE. 

Supporting the fragments with a nickel-plated or gilded needle, which 
is made to transfix the nose at a point just below the fragments, was first 
suggested by Dr. Lewis D. Mason, of Brooklyn, in 1880. 1 The pin is 
removed on the eighth or tenth day, or as soon as the fragments are 
sufficiently united not to require support. A narrow strip of rubber 
bandage is to embrace the ridge of the nose. 

§ 2. Fractures and Displacements of the Septum Narium. 

Fractures or displacements of the septum narium must occur to some 
extent in all fractures of the ossa nasi accompanied with depression ; but 
they are also occasionally met with as the results of a blow upon the nose 
which has been insufficient to break the bones, and in which only the 
cartilaginous portion of the nose has been bent inward upon the septum. 
In four of my eight of these simple, uncomplicated accidents, no surgeon 
was employed, or surgical treatment of any kind adopted, and it is quite 
probable that only in a small proportion of all the cases was the nature 
of the accident recognized. Such, at least, has been generally the state- 
ment of the patients themselves. The same causes will explain this 
which have been invoked to explain similar oversights in cases of broken 
ossa nasi. An additional reason that it may be overlooked is the fre- 
quency of lateral distortions or deviations in the natural development of 
this septum. 

The cartilaginous portion of the septum is most frequently displaced 
by violence, usually at the point of its articulation with the bony septum. 
Next in frequency, the perpendicular nasal plate is broken, especially 
where it approaches the vomer. We omit those cases where the nasal 
bones themselves are broken down, in most or all of which the perpen- 
dicular plate is more or less fractured and displaced. We do not know 
how often the vomer is broken, since it is beyond our observation, except 
in autopsies. It is probable that the force of the concussion rarely 
reaches it, the cartilage or the perpendicular plate giving way first and 
easily. 

Where the deviation is only lateral, the results are less serious, yet 
sufficiently so, in a few instances, to demand our attention. Lateral 
obliquity of the lower portion of the nose follows generally, but not 
uniformly, a lateral displacement of the cartilage ; and when it does 
exist, it is not always proportioned to the amount of displacement exist- 
ing in the septum, so that the septum is then made to project obliquely 
across the nasal passage, causing often a serious obstruction and per- 
manent inconvenience. It may occasion a chronic catarrh. 

A lad, aged fifteen, was struck violently on the nose, which became immedi- 
ately much swollen, but no surgeon was called. Eight years after I found the 
septum displaced laterally, and to the left side, producing also a slight lateral 
inclination of the end of the nose. He was unable to breathe freely through 
the left nostril, and from the same side a catarrhal discharge had continued 
from the time of the accident. 

1 Mason, Annals of the Anatomical and Surgical Society of Brooklyn, March, 1880. 



FRACTURES OF THE SEPTUM NARIUM. 101 

A depression of the cartilage forming a portion of the ridge of the 
nose is necessarily accompanied with a corresponding degree of lateral 
displacement, with or without fracture, of its perpendicular portion, and 
produces, therefore, not only great deformity, sometimes a complete 
flattening of the end of the nose, but, also, in some instances, complete 
obstruction of the nostrils. 

We may conclude, therefore, that fractures and displacements of the 
septum narium are generally followed by permanent deformity, and occa- 
sionally with still more serious results ; and hence we suggest that there 
should be a careful examination in recent injuries, with a view to the 
ascertainment of its lesions. 

Treatment. — The treatment is not reliable. It is doubtful if a partition 
so thin and unsupported can be well adjusted and supported by artificial 
means. A rational method would be to plug carefully and equally each 
nostril with pledgets of lint, and cover the outside of the nose completely 
with a nicely moulded gutta-percha splint or case; this ought to be made to 
press snugly upon the sides, and should remain for several weeks, or until 
the cure is completed. The papier mache of Dzondi, employed by him 
in cases of broken ossa nasi, would be equally applicable here ; but the 
gutta-percha, as being more plastic, and hardening more quickly, ought 
to be preferred. 

The remedy of deformities of the nose at a later period belongs to 
the department of anaplastic surgery, and the modes of procedure 
must be varied according to the circumstances of the case. The fol- 
lowing example will serve as an illustration : 

A young man fell from a two-story window, striking upon his face. A 
surgeon was called, but he did not discover the nature of the injury to the 
nose. One year after the accident the cartilaginous portion of the septum was 
found broken just at the ends of the nasal bones, and forced backward about 
three lines, producing a striking depression at this point of the ridge of the nose, 
whilst at the same time the end of the nose was thrown up. I introduced a 
narrow, sharp-pointed bistoury through the skin of the nose on the right side, 
and resting its edge upon the ridge at the junction of the cartilage with the ossa 
nasi, cut the cartilaginous septum directly backward about three lines; then, 
making a gradual curve, I cut downward about eight lines toward the end of 
the nose. The intercepted portion of cartilage could now be easily lifted 
with a probe, and the line of the ridge of the nose completely restored. It was 
at once apparent, also, that lifting the cartilage would depress the tip of the 
nose and restore its symmetry. 

To retain the cartilage in place, I constructed a gutta-percha splint of the 
length and shape of the nose, but so formed along its middle as that it would not 
press upon the cartilage which I had lifted, resting well upon the ossa nasi, but 
not touching the ridge from the low T er ends of these bones to the tip of the nose, 
at which latter point it again received support. I now passed a needle, armed 
w T ith a stout ligature, through the upper end of the uplifted cartilage, transfixing, 
of course, the skin on both sides of the nose, and this I tied firmly over the 
splint. This accomplished the important object of pressing backward and down- 
ward the tip of the nose, and thus tilting up the upper part of the ridge and 
septum, and of more effectually securing the cartilage in place by lifting it 
directly with the ligature. On the second day the ligature was removed, but the 
splint was continued two weeks, during most of which time a band was kept 
drawn across the lower end of the splint, and tied behind the neck. To prevent 
the cartilage from falling back when cicatrization occurred, I pressed the sides 
of the splint firmly toward each other, just below the incision, so as to force as 
much as possible the walls of the nares into the fissure of the septum, made by 



102 FRACTURES OF THE MALAR BONE. 

lifting it up. The result is a complete and perfect restoration of the nose to its 
original form. 

To rectify an old displacement of the septum, Dr. James Bolton, of 
Va., makes a stellate incision of the septum in such a manner as to form 
of it about eight triangles with their apices converging to a common 
centre. He then seizes each triangle separately with a pair of forceps, 
and breaks it at its base without detaching it. Having thus comminuted 
the septum, he is able to restore it to position and retain it until consoli- 
dation is effected. 1 



CHAPTEE X 



FRACTURES OF THE MALAR BONE. 

A simple fracture of the malar bone — that is, a fracture unconnected 
with a fracture of other bones of the face — probably sometimes occurs, but 
not being accompanied with much displacement, it is overlooked. I have 
myself seen a fracture of the upper margin, or of that portion which con- 
stitutes a part of the orbital border, in two or three instances, while I 
was unable to detect any other fracture among the bones of the face ; but 
it is by no means certain that other fractures did not exist, perhaps in 
some of the bones which form the socket, or in the superior maxilla, as 
mere fissures, or as fractures with only slight displacement. The promi- 
nence of the malar bone, and especially the sharpness of its orbital mar- 
gin, would enable the surgeon to detect easily the smallest displacement, 
or even a fissure, whilst a much more extensive displacement elsewhere 
would escape detection. 

The two upper maxillary bones form, as they are placed opposite to 
each other, an irregular arch, one end of which rests upon its fellow, at 
the intermaxillary suture, and the other end rests upon the nasal and 
frontal bones ; whilst over the centre of the arch is situated the malar 
bone. The force of a side blow upon the malar bone will expend itself, 
therefore, chiefly upon the base of the maxillary apophysis, as being in 
the line of the direction of the force. The force continuing to act after 
the apophysis is broken, the portion of the superior maxilla above the 
floor of the nares will fall inward toward the septum, while the portion 
below will tilt outward, and open the intermaxillary suture along the 
roof of the mouth. This suture will also open more widely in front than 
behind, owing to the greater depth of the suture in front. 

These observations I have verified by several experiments made with a hammer 
upon a clean skull as follows : A fracture of the superior maxilla occurred in 
every instance, and twice when the malar bone was not broken ; in each of the 
last two cases the antrum alone was broken, and the depression of the malar 
bone was scarcely noticeable. In the second of these cases, the fracture extended 
also through the dental arcade. In three cases the nasal apophysis was broken 

1 Bolton, Richmond Med. Journ., April, 1868, p. 241. 



FRACTURES OF THE MALAR BONE. 103 

near the base, and in one case at two points. One of the three fractures of the 
nasal apophysis was accompanied with a diastasis of the superior maxilla through 
its intermaxillary suture. The malar bone has been broken twice by the first 
blow, and always when the blow has been repeated. The orbital margin and 
orbital plate have been fissured twice, the outer portion of the orbital plate being 
pushed a little into the socket. Once this plate has been pushed downward. 
The zygoma has been broken three times, and always transversely a little beyond 
its centre, or where the bone is the most slender and most convex. The ethmoid 
has been broken three times, and always longitudinally through the orbital plate. 
The sphenoid has been broken once, at the base of the skull by the second blow. 
In the last experiment, the skull was also found broken at its base, through the 
lesser wings of Ingrassias ; the force of the blow having been conveyed, appar- 
ently, along the orbital plate of the superior maxilla and os planum. This is the 
only example from four experiments in which the fracture extended through 
the dental arcade, and it was the result of the first blow. The fracture of the 
base of the skull by the second blow indicates the possibility of producing a 
fatal lesion of the brain or of its bloodvessels by a blow upon the malar bone. 

Prognosis. — The malar bone may be depressed, as we have seen, to 
the extent of two or three lines, without being broken. This accident 
will be more properly considered under fractures of the upper maxilla, 
A fracture of the malar bone implies, therefore, generally, that great 
force has been applied, and that other fractures exist as complications. 
This may not be true, however, when only the orbital margin of the 
socket is broken. If the orbital plate is broken, and a portion of it is 
pushed into the socket, it may occasion a slight protrusion of the ball, as 
in two cases related by Dr. Neill as fractures of the upper maxilla, and 
as has been noticed in the experiments already referred to. This pro- 
trusion of the eyeball will probably continue, in some degree, as long as 
the bones remain displaced. It is quite probable, however, that in some 
cases, after severe injuries of the face, a moderate protrusion of the eye- 
ball is due entirely to extravasation of blood in the socket ; a circumstance 
which would be likely to follow a fracture of the bones of the socket, and 
to increase temporarily the protrusion of the eye. If the body of the 
bone is broken entirely through, and coma supervenes upon the accident, 
there is some reason to fear that the skull is fractured at its base, and 
the prognosis must be grave. 

Treatment. — It would not appear difficult to restore these bones to 
place upon the naked skull after an accident, but, in fact, I have found 
the restoration impossible. It could not be accomplished by an instru- 
ment w T ithin the nose pressing outward, nor by pressing inward upon 
the teeth and alveoli : not, certainly, without very great and unwarrant- 
able force. The difficulty consisted simply in the antagonism of the 
serrated margins of the intermaxillary suture, which, projecting one or 
two lines on each side, could not be made to interlock again, but were 
firmly braced against each other. If there is only a fissure of the orbital 
margin, it will not require attention ; but if the fissure extends through 
the orbital plate, and at the same time the anterior and inferior margin 
of the bone is depressed, in consequence of which the orbital plate is 
tilted upward and made to push forward the eyeball, the propriety of 
surgical interference may be considered. If this protrusion is consider- 
able,, and evidently due to the displaced bone, an attempt should be made 
to lift the body of the malar bone, and thus to restore to position its 



104 FRACTURES OF UPPER MAXILLARY BONES. 

orbital plate. The method of accomplishing this will be described par- 
ticularly when speaking of fractures of the superior maxilla with de- 
pression of the malar bones. 



CHAPTER XL 

FRACTURES OF THE UPPER MAXILLARY BONES. 

These fractures assume so great a variety in respect to form, situation, 
and complications, that it is impossible to speak of them systematically, 
or to establish other than general rules as to prognosis and treatment. 
They may be broken, or loosened from each other or from the other 
bones with which they are articulated, with or without any further frac- 
ture ; the nasal processes may be broken, generally with a fracture of 
the nasal bones also ; the malar bones may be forced in, carrying with 
them a portion of the outer wall of the antrum ; the alveoli may be 
broken and more or less completely detached ; either of these several 
fractures may be complicated with fractures of the other bones of the 
face, or of the base of the skull even. 

Prognosis. — Malgaigne remarks : " In all complicated fractures of the 
upper jaw, there is one principle which surgeons cannot too much study, 
namely, that all fragments, however slightly adherent they may be, ought 
to be most carefully preserved, and they will be found to unite with 
wonderful ease. This remark had already been made by Saviard. Larrey 
insists strongly upon it, and we have seen that M. Baudens, so great an 
advocate for the removal of loose fragments, has declared for these frag- 
ments a special exemption." 1 Malgaigne has here especial reference to 
fractures of the dental arcade, and to fractures implicating the alveoli, 
and extending more or less into the body of the bone. 

Exceptions have, however, occurred in my own practice, the fragments be- 
coming loosened and completely detached after the lapse of several weeks. In 
the case related by Miller, the whole floor of the antrum having been broken 
off, in an unskilful attempt to extract the second right upper molar, it was found 
impossible to make it unite, and it was subsequently removed. 2 Such unfor- 
tunate results certainly may sometimes be reasonably anticipated. Yet they 
occur so seldom as to justify the opinions and practice advocated by Malgaigne. 

Our experience during the War of the Rebellion in this country con- 
firms most of the observations heretofore made in relation to these frac- 
tures. Owing to the extreme vascularity of the bones composing the 
upper jaw. the fragments have been found to unite, after the most severe 
gunshot injuries, with 'surprising rapidity: the amount of necrosis and 
caries being usually inconsiderable, compared with the amount of com- 
minution. The same anatomical circumstance, namely, the vascularity, 
has rendered these accidents peculiarly liable to troublesome hemorrhages, 
both primary and secondary. 

1 Op. cit., vol. i. p. 376, Paris ed. 2 Miller, News Letter, April, 1854. 



FRACTURES OF UPPER MAXILLARY BONES. 



105 



The Surgeon-General reports that of 4167 wounds of the face, tran- 
scribed from the reports from the beginning of the war to October, 1864, 
there were 1579 fractures of the facial bones, and of these 891 recovered, 
107 died — the terminations are still to be ascertained in 581 cases. He 
further remarks that secondary hemorrhage has been the principal source 
of fatality in these cases, and that frequent recourse has been had to 
ligation of the carotid, with the result of postponing for a time the fatal 
event. 1 

Treatment. — When the harmonies of the upper maxillary bones are 
only slightly disturbed, nothing but a retentive treatment is necessary. 

A man was thrown backward from a loaded cart, one wheel of the cart passing 
over his face. The right malar bone was broken and forced down upon the 
antrum about three lines. Both superior maxillae were loosened from their artic- 
ulations, and could be moved laterally, the motion producing a slight grating 
sound. The same motion and grating occurred whenever he attempted to swal- 
low. No effort was made to elevate the malar bones, the amount of displacement 
being very inconsiderable, and never sufficient to be observed by the eye. Cool 
lotions were applied constantly to the face, and the patient was sustained by a 
liquid diet. On the ninth day all motions of the fragments had ceased, and on 
the twenty-seventh day the patient was completely recovered, with only the 
depression of the malar bone remaining. 

In a case in which the superior maxillary bones had been more com- 
pletely torn from their connections, complicated with other severe inju- 
ries, I found it necessary to support 

the fragments by closing the lower jaw FlG - 34 - 

upon the upper and by suitable ban- 
dages. 

Graefe recommends, where the bones are 
thus extensively separated and displaced, 
an apparatus made of steel, and suitably 
covered, which is to be applied against the 
forehead and buckled under the occiput. 
From which apparel, in front, descend a 
couple of steel plates, which, having ar- 
rived at the free border of the upper lip, 
are reflected upon themselves, and are 
made to support upon their extremities 
long silver gutters, intended for the recep- 
tion of not only the displaced teeth and 
alveoli, but also those teeth which are 
firm. 2 Goffres has employed a similar ap- 
paratus, only that he has substituted gutta- 
percha for the silver gutters of Graefe. 3 In 
Goffres's case the apparatus was made to 
support a pad also, intended to make lat- 
eral pressure over the displaced fragments. 
No doubt cases may now and then occur in 
which this apparatus would serve a useful 
purpose. 




Goffres's modification of Graefe's 
apparatus. 



In most cases two interdental splints of gutta-percha, placed one on 
either side, leaving an open interval in front for the purpose of conveying 



1 Circular, No. 6, 1865. 2 Traite des Frac, etc., par L. F. Malgaigne, p. 373. 

3 Goffres, Bullet, de l'Acad. de Med., 1862, t. 27, p. 1157, from Poinsot. 



106 FRACTURES OF UPPER MAXILLARY BONES. 

food to the stomach, will accomplish every indication, and in a manner 
much more comfortable to the patient, and more satisfactory to the sur- 
geon, than any form of mechanical apparatus. A pad or compress upon 
the side of the face, supported by a roller, is better than the pad attached 
to one side of Groffres's apparatus, as a means of lateral support. 

Wiseman, having been summoned to a child with his whole upper jaw forced 
in by the kick of a horse "beating the ethmoides quite in from the os cribri- 
forme," and forcing the palate bone against the back of the pharnyx, found 
great difficulty in securing a permanent readjustment. At first he attempted to 
introduce his finger back of the bone ; but, failing in this, he bent an instru- 
ment into the form of a hook, and, passing it between the bone and the pharynx, 
he easily replaced the fragments. But, on removing the instrument, they were 
again displaced. Immediately he had constructed an instrument by which the 
bones could be not only easily reduced, but also retained in place, extension 
being made by the hands of the child, his mother, and others, alternately. In 
this way the reunion was finally effected, and " the face restored to a good shape, 
better than could have been hoped for." 1 

Harris, of New York, mentions a case in which a child, two years old, having 
fallen from a height, was found to have a diastasis of both the superior maxil- 
lary and palate bones; the separation being sufficient to admit the little finger, 
and extending from between the alveoli which supported the central incisors, to 
the soft palate. It is not stated that efforts were made to reduce the bones ; six 
weeks after the injury was received they were still open, and it was proposed to 
close the space by a plastic operation as soon as the condition of the patient would 
warrant such a procedure. 2 

In this example, as in my experiments in fracture of the malar bone, it was 
probably found impossible to adjust the bones and close the inter-maxillary 
suture, and for the same reasons. 

If, in consequence of a blow received upon the ossa nasi, the nasal 
processes of the superior maxilla are broken down, they may be lifted 
and adjusted in the same manner as the ossa nasi. 

I have a specimen, in which the nasal bones being driven in by the kick of a 
horse, the nasal process upon the left side is broken off just above the root of the 
cuspid tooth, and its upper end inclined inward toward the nasal passage and 
backward, until it is completely buried. In this situation it has become firmly 
united to the bony and soft tissues into which it was brought in contact. 

The following example will illustrate some of the complications and difficul- 
ties connected with a depression of the malar bone, and consequent fracture of 
the antrum maxillare : 

M. P., aged about thirty- four years, was thrown from a height, striking upon 
his face, forcing the right malar bone down upon the antrum of the superior 
maxilla. The deformity produced by the sinking of the malar bone was very 
striking. We found some of the teeth upon the side of the fracture loose, and 
we determined to extract them, and press up the bone with an instrument intro- 
duced through the empty sockets. The first attempt to extract a molar tooth, 
however, brought down several teeth, and the whole floor of the antrum. The 
detachment of this fragment was also now so complete that we believed it neces- 
sary to remove it entirely, a labor which was accomplished with infinite diffi- 
culty, and with no little hazard to the patient, as dissection had to be extended 
very far back into the throat, and in the end it was not effected without bring- 
ing out, attached to the fragment of maxillary bone, a considerable portion of 
the pyramidal process of the os palati. The time occupied in this operation 
was at least one hour, during which we were every moment in the most painful 
apprehensions, lest we should reach and wound the internal carotid, which lay 

1 Ckirurgical Treatises, by Richard Wiseman, 1734, p. 443. 

2 New York Journ. Med., vol. xiii., 2d ser., p. 214. 



FRACTURES OF UPPER MAXILLARY BONES. 107 

in such close juxtaposition to the knife that we could distinctly feel its pulsation. 
After its removal the hemorrhage was for an hour or more quite profuse, and 
could only be restrained by sponge compresses pressed firmly back into the mouth 
and antrum. When the hemorrhage was sufficiently controlled, we proceeded 
to examine the antrum, the floor of which being removed entire, permittted the 
finger to enter freely. The restoration of the malar bone was now accomplished 
without much difficulty, and with only moderate force. Two years after the 
accident the face presented, externally, no traces of the original injury. The 
malar bone seemed to be as prominent as upon the opposite side, and there was 
no perceptible falling in where the teeth and alveoli were removed. During 
several months after the removal of the bone, the antrum continued to discharge 
pus, but at length a semi-cartilaginous structure closed in the cavity below, 
entirely reconstructing its floor, and the discharge ceased. Since then he has 
experienced no further inconvenience. 

In many instances no difficulty will be experienced in resorting to the 
usual method. The recent loss of one or more teeth opposite the floor of 
the broken antrum, or the complete displacement of a tooth by the acci- 
dent itself, will give an opportunity for the perforation of the antrum 
through the open socket, and for the introduction of a suitable instrument 
for lifting the depressed bone. 

Unless, however, the opening is quite large, the instrument employed must 
be so small, such as a straight steel sound or a female catheter, as to expose 
the parts against which its end is made to press, to some risk of being broken 
and penetrated. It is even possible in its way to penetrate the socket of the eye, 
and thus inflict serious injury upon the eye itself. Yet, with some care, such 
accidents may be avoided, and it is probable that in the cases supposed, where 
the sockets of the teeth opposite the base of the antrum are open, this method 
will continue to have the preference. 

But if the teeth remain firm in their places, or if they have been 
removed, and the sockets are filled up, and we "wish to enter the antrum 
at its base, we must either drill through its anterior wall above the roots 
of the teeth, or we must proceed to extract a tooth. The first method 
gives an inconvenient opening, and one through which it will be neces- 
sary to use a curved instrument ; but yet it is a method far less objec- 
tionable than the extraction of a tooth which is firm, or which is even 
tolerably firm, in its socket, and which may require the forceps for its 
removal. 

The objections to this latter procedure were suggested by the tedious and 
painful operation already detailed. The first attempt to extract a tooth brought 
down the whole floor of the antrum, with all its corresponding teeth, and the 
pyramidal process of the palate bone. The tooth was already loose, and w r e 
thought it might easily be taken out; but it had not occurred to us that it was 
loosened by the comminuted condition of the walls of the antrum, and of the 
dental arcade. The experiments made upon the dead subject would seem to 
show that this fracture and comminution of the alveoli is not a very frequent 
result of a fracture of the antrum produced by a blow upon the malar Done ; yet 
it may happen, and whenever it does, the attempt to extract a tooth must always 
expose the patient to the same hazards. Certainly it is no trifling matter to pull 
away all of a man's upper teeth upon one side, and to open freely into a broad 
cavity which might never close again, and which, in this event, must always 
serve as a place of lodgment for particles of food, and for foul secretions, to' say 
nothing of the external deformity which it is likely to produce, and of the 
severity and even danger of the operation. 



108 FRACTURES OF UPPER MAXILLARY BONES. 

The following procedures, the value of which I have been able to 
determine by experiment upon the living subject in two or three cases, 
and which I have carefully and frequently tested upon the cadaver, are 
suggested : 

Attempt to lift the bone by putting the thumb under its zygomatic 
process and body within the mouth. If the bone is thrown directly 
downward, or downward and backward, this method can scarcely fail ; 
and even when it is thrown downward and forward, so as to press into 
the antrum, it is likely to succeed. If, however, for any reason, the 
thumb cannot be brought to bear upon its under surface, make a small 
incision upon the cheek over the anterior margin of the masseter muscle, 
where its insertion into the malar bone terminates, and pushing a strong 
blunt hook under the bone, lift it. 

Where the depression of the malar bone is in the direction of the an- 
terior and superior angle, these means may not be found available, and 
we may then employ a screw elevator. The instrument ought to be made 
of the best steel, and with a broad, sharp- cutting thread. A slight in- 
cision being made through the skin, and down to the centre of the malar 
bone, the elevator is then screwed firmly into its structure, and now its 
elevation and adjustment may be accomplished with the greatest ease. 

In some instances, where fragments are displaced, carrying with them 
several teeth, while others in the same row remain firm, it will be suffi- 
cient to close the mouth and apply a bandage as for fracture of the 
inferior maxilla ; in others, the teeth and their alveoli ought to be 
fastened with silk, or gold or silver thread ; gold, silver, gutta-percha, or 
vulcanite clasps may be applied to the teeth and jaw. 

In a case of fracture of the right superior maxilla, reported by Baker, of 
Norwich, N. Y., complicated with a fracture of the inferior maxilla, the alveoli 
were retained in place very perfectly by a mould of gutta-percha. Neill, of 
Philadelphia, has also reported three cases of fracture of the bones of the face, 
involving the superior maxilla, in two of which the eyes were made to protrude 
more or less from their sockets. The loosened alveoli were made fast by wire. 
The subsequent deformity was inconsiderable, yet in no instance was the restora- 
tion complete. The same method was adopted successfully by a surgeon in 
Virginia, in the case of a negro fifty years old, where most of the teeth of the 
left upper jaw were forced into the mouth, carrying with them their correspond- 
ing alveolar processes. The teeth remained firm in their sockets, but the separ- 
ation of the bone was complete, the fragment being held in place only by the 
mucous membrane of the mouth. On the eighth day the surgeon found that 
the negro had removed the wire, and also the cork from between his teeth, and 
the maxillary bandage; but the soft parts had already united, and the bones 
showed no tendency to displacement. His recovery was speedy, and it was 
accomplished without any further treatment. 

[Marshall, of Chicago, reports two cases of fracture and diastasis of the superior 
maxillae and upper bones of the face successfully treated with the aid of the 
inter-dental splint. In both cases the cause was a crushing blow which drove 
the maxilla inward. The apparatus employed was adapted on the principle of 
Kingsley's inter-dental splint, and gave excellent results. 1 ] 

1 Journ. Amer. Med. Assoc, 1888, vol. ii. 



FRACTURES OF THE ZYGOMATIC ARCH. 109 



CHAPTER XII. 

FRACTURES OF THE ZYGOMATIC ARCH. 

The zygoma, strictly speaking, is formed in a great measure by the 
body of the malar bone, and it is broken whenever the malar bone is 
completely separated through any portion of its body. That portion 
will be considered which is composed of the two processes, called respec- 
tively the zygomatic processes of the malar and temporal bone. 

Duverney relates a case in which a young child, having in his mouth the end 
of a lace-spindle, fell forward and thrust the spindle through the mouth from 
within outward, breaking the zygoma in the same direction, and leaving the 
fragments salient outward. 1 To which case of outward displacement Packard, 
in a note to Malgaigne's work on fractures, etc., has added a second. 2 

■ Experiments upon the naked skull show that the zygoma may be 
broken and displaced in the same direction, by any force which shall 
fracture the superior maxilla and depress the anterior margin of the 
malar bone. This happened three times, and always at the same point, 
viz., a little beyond the middle of the zygoma, near -where the suture 
which joins the two processes terminates below. The fractures were 
always transverse, and not in the line of the suture. They were, there- 
fore, fractures of that portion of the zygoma which belongs to the tem- 
poral bone. 

Symptoms. — An irregular projection or depression of the fragments 
is the only sign which can be relied upon to indicate the existence of this 
accident ; and this must often be concealed by the swelling which follows 
so rapidly wherever the integuments are severely bruised over a super- 
ficial bone This displacement can scarcely occur in but two directions, 
either outward or inward ; since the attachments of the temporal aponeu- 
rosis above, and of the masseter muscle below, must effectually prevent 
its descent or ascent. Neither motion nor crepitus will often be present. 
In some cases the difficulty in opening or shutting the mouth, occasioned 
by the projection of the fragments toward or into the tendon of the tem- 
poral muscle, or by the inflammatory effusions, may assist in the diag- 
nosis. 

Prognosis. — If the fracture has been produced indirectly by a depres- 
sion of the malar bone, the prognosis must depend upon the amount of 
injury done to the other bones of the face; in itself, the fracture of the 
zygoma cannot be a matter of any moment. The same remark might 
apply also to any fracture of the zygoma in which the angles were salient 
outward. If, on the contrary, the angle is salient inward, the fracture 
having been produced by a blow inflicted directly upon the zygomatic 
arch from without, or by a blow upon the outer portion of the malar 

1 Duverney, Bulletin de la Societe Anatomique, p. 138, 1810. 

2 Malgaigne, Amer. ed., p. 289, vol. i. 



110 FRACTURES OF THE ZYGOMATIC ARCH. 

bone, it may occasion some embarrassment to the action of the temporal 
muscles. If the force which produces the fracture has acted more upon 
the temporal portion of the arch, near where the process arises from the 
temporal bone, it may be accompanied with a fracture of the skull, and 
with serious cerebral lesions. 

Treatment. — A fracture, accompanied with an outward displacement, 
and occasioned by a depression of the malar bone, will be adjusted by a 
restoration of the malar bone in the manner already described, when 
speaking of fractures of the superior maxilla, etc. If the fragments are 
displaced outward, in consequence of a direct blow from within, then 
they may be replaced by pressing upon the projecting angle. 

When the fragments, in consequence of a direct blow from without, 
have been driven inward, and, as a consequence, serious embarrassment 
to the motions of the temporal muscle ensues, an attempt ought to be 
made at once to replace them ; if, however, no impediment to the action 
of the muscle exists, no surgical interference will be required. A slight 
amount of embarrassment may be the result of the direct injury to the 
muscle inflicted by the blow, without reference to the displacement of the 
bone, and a few days will suffice to remedy this evil entirely. Where 
the fragments actually penetrate the muscles and remain thus displaced^ 
the points are gradually absorbed, and rounded, so that after a time they 
constitute no impediment to the action of the muscles. It is not the 
muscle, but its tendon, which is liable to be penetrated ; and this is 
usually protected somewhat by a plate of soft adipose tissue lying between 
the tendon and the arch. If to these considerations we add the diffi- 
culties likely to be encountered in the reduction, we shall find but few 
cases in which a resort to surgical interference will be necessary. If the 
bone is driven toward the tendon of the temporal muscle at or near its 
centre, and if its restoration becomes necessary, it can be accomplished 
only by approaching the bone from without. 

Dupuytren found an external wound through which, by the aid of a levator, 
he easily restored the fragments to place. M. Ferrier, however, of the Hospital 
of Aries, in a case brought before him, made an incision through the integu- 
ments down to the bone, and then attempted to slide underneath the small 
extremity of a spatula ; but the aponeurosis would not yield, and he was obliged 
to cut it also. He was now able to lift the fragments easily. The wound healed 
rapidly, and the patient was dismissed without any deformity. 1 

[A case came under the care of Levis, of Philadelphia, in which the depressed 
arch was caught against the coronoid process of the lower jaw, causing fixation. 
He elevated the fragment through an incision just above the zygoma, when the 
lower jaw was at once set free. 2 

Mr. Le Gros Clark met with a case where, at the end of three weeks, the 
trismus was so extreme, owing to the driving in of the arch, that he was totally 
unable to separate his jaws or to move the lower maxilla at all. No operation 
was performed, and the patient in time entirely recovered, and with slight 
deformity. 3 ] 

1 Ferrier, Bulletin des Sciences Med., torn. x. p. 160. 

2 Polyclinic, Philada., 1886. 

3 St. Thomas's Hosp. Eeps., 1887. 



FRACTURES OF THE LOWER JAW. Ill 



CHAPTEE XIII. 

FRACTURES OF THE LOWER JAW. 

Of 55 examples of fracture of this bone which have been recorded by 
me, not including gunshot fractures, 52 were broken through some por- 
tion of the body. An analysis of 45 of the above examples shows that 
16 were broken completely asunder at two or more points, constituting 
double and triple fractures; and of the remainder, 5 were accompanied 
with detachment of portions of the alveoli, and one with detachment of 
a considerable fragment from the body. 13 were compound; not in- 
cluding in this enumeration several examples in which the partial or 
complete dislodgment of a tooth might entitle them to be called com- 
pound. Four fractures through or near the symphysis were nearly or 
quite vertical, and most of the others were known to be oblique. 

Malgaigne has remarked, also, that in fractures of the body of the bone the 
direction of the obliquity is generally such that the anterior fragment is made 
at the expense of the internal face of the bone, and the posterior fragment at 

Fig. 35. 




the expense of the external face, this latter overriding the former. Buck, of 
New York, has seen the fragments in an opposite condition, requiring the use 
of the knife and saw for their extrication. 1 I have myself recorded one similar 
example, but in which the fragments were easily replaced. 

In 30 examples of fractures through the body, not including fractures 
of the symphysis, the line of fracture has been observed to be 20 times 
at or very near the mental foramen, 3 times between the first and 
second incisors, 4 times behind the last molar, and 3 times between the 
last two molars. 

Boyer was of the opinion that a fracture never takes place in the 
symphysis of the chin ; but many surgeons since his time have noticed 
this fracture, and Malgaigne assures us that J. Cloquet has demonstrated 
its existence upon an anatomical specimen. 

1 Buck, New York Joum. Med., March, 1847. Proceedings of IT. Y. Med. and Surg. 
Soc, Sept. 19, 1846. 



112 FRACTURES OF THE LOWER JAW. 

Stephen Smith, of New York, has seen two examples; 1 Lonsdale mentions 
three ; 2 and Gibson has seen one ; 3 and I have met with two, both of which are 
recorded in the early editions of this book. Velpeau, Fergusson, Gibson, Henry 
Smith, and others, have remarked that a separation at the symphysis takes place 
usually in infancy or childhood. But in the examples in which I find the ages 
reported, only one, a case mentioned by Lonsdale, occurred in a person as young 
as ten years; in one' of the cases seen by myself, the patient was seventeen years 
old, and the remainder ranged from twenty-five years to sixty ; and the average 
age of all is thirty-two years. 

A fracture of the ramus occurred in a man twenty-three years old, 
who had been struck by a wooden block on the side of his face. The 
ramus was broken just above the angle, and the body was broken, also, 
obliquely near the symphysis. The intercepted fragment was carried 
inward. 4 I met with another similar case at Bellevue Hospital, in a 
woman. 

Ledran mentions the case of a child, ten or twelve years old, in whom the 
fracture was double also ; one fracture having taken place through the body, 
and one extending obliquely from the root of the coronoid process to the neck 
of the condyle. The intercepted fragment was, however, so little displaced that 
the fracture of the ramus was not discovered until after death. 5 Malgaigne 
refers to this as the only example recorded ; but Stephen Smith, of the Bellevue 
Hospital, has met with it four times : in one case the ramus was broken on both 
sides ; in two cases one ramus only was broken ; and in one the body was 
broken on the right side and the ramus on the left. 6 In two of these examples 
the fragments were not displaced. 

The coronoid process is so well protected by muscles and by the sur- 
rounding bony projections, that it is very rarely broken. 

Houzelot mentions a case in which a fall from a height produced at the same 
time a fracture of both condyles, of both coronoid processes, and of the sym- 
physis. 7 

Nine cases of fracture of the condyles have been reported, in all of 
which the separation occurred through the neck, and just below the 
insertion of the external pterygoid muscle. 

According to Malgaigne, the analysis of these cases, excepting those mentioned 
by Packard and Watson, shows two classes of examples : the one occasioned by 
falls or blows upon the chin, and producing a simple fracture of the neck of the 
condyle; the other occasioned by injuries inflicted upon the side of the face, 
and producing a fracture of the neck on the side corresponding to that upon 
which the injuries are received, and at the same time a fracture of the body 
upon the opposite side. These two varieties seem to be about equally common. 

In Houzelot's case there existed also a fracture of both condyles, of both 
coronoid processes, and at the symphysis. In Watson's case the face was some- 
what deformed by the retraction of the chin ; the mouth could not be opened 
so as to protrude the tongue to any great extent beyond the teeth, and the teeth 
of the upper and lower jaws could not be brought into contact. In attempting 
to move the jaw, the patient experienced pain and crepitation just in front of 
the ears; the crepitation could easily be felt by placing the fingers over the 

1 Smith, New York Journ. Med., Jan. 1857, Hospital Reports. 

2 Practical Treatise on Fractures. By Edward F. Lonsdale, London, 1838, p. 226. 

3 Institutes and Practice of Surgery. By William Gibson. Philada., 1841, p. 261. 

4 Trans. Amer. Med. Assoc, vol. viii. p. 385. Report on "Deformities after Fractures," 
Case 17. 

5 Malgaigne, op. cit.. p. 337, from Ledran, Observ. Chirurg., torn. i. obs. vii. 

6 Smith,' ISTew York Journ. of Med., Jan. 1857. Bellevue Hosp. Reports. 

7 Malgaigne, op. cit., p. 400. 



FRACTURES OF THE LOWER JAW. 113 

fractured condyles. Nothing was done for the fractures of the jaw. In a few 
weeks the rubbing of the broken surfaces and attendant soreness ceased to 
trouble him ; but the shape of the jaw, and difficulty of opening the mouth to 
any great extent, still remained unaltered. 1 

Etiology. — The causes have generally been direct blows, in most in- 
stances inflicted by a club, or by the kick of a horse ; in tw T o examples 
the blow was inflicted by the fist. A fracture immediately in front of 
the right cuspid, in a lad eight years of age, was produced by pressure 
between two wagons, made, upon the two angles of the jaw. A double 
fracture was produced in a young woman by the grasp of her husband's 
hand. In ten of eleven cases mentioned by Stephen Smith, the causes 
were direct blows. Examples of fracture of the inferior maxilla from 
indirect blows have, however, been mentioned by other surgeons, the 
angles of the bone being pressed together by the passage of a wheel, and 
the fracture taking place usually toward the symphysis. Fractures of 
the condyles belong to two classes : 2 the one being occasioned by falls 
upon the chin, and the other by blows upon the side of the face ; the 
former acting as a counter-force, and the latter as a direct. The coronoid 
process can only be broken by a direct blow. 

Symptoms. — Fractures of the body of the bone are characterized by 
the usual signs of fracture elsewhere, namely, displacement, mobility, 
crepitus, and pain. The displacement is generally present ; but its 
direction and amount vary according to the situation and course of the 
fracture, and also according to the violence and direction of the force 
producing the fracture. 

I have seen several cases unaccompanied with displacement, and one of these 
I think ought to be regarded as an example of a partial fracture. A lad, set. nine, 
was kicked by a horse on the right side of the jaw. I could not detect any frac- 
ture, but the body of the jaw seemed to be bent in. On the third day, however, 
while endeavoring to straighten the jaw by violent pressure from within outward, 
I detected a feeble crepitus, which on more careful examination proved to be 
opposite the second incisor of the right side. I was also able to detect a slight 
motion at the same point. It was found impossible to rectify the bending, and 
no further efforts were made. After the lapse of nearly a year, the natural curve 
was found to be partially, but not completely, restored. Ledran and other sur- 
geons have also seen examples where neither the periosteum nor mucous mem- 
brane was torn. 

In fractures of the body, the anterior fragment is generally depressed. 

Malgaigne affirms that where an overlapping occurs, the anterior fragment lies, 
generally, within the posterior; a fact which he explains by the direction which 
the line of fracture usually takes, namely, from without inward and backward, as 
we have already mentioned. In one instance, where the jaw was broken at the 
symphysis and also on both sides through the body, the central fragments were 
found, after about four weeks, lifted two lines above the lateral fragments, and 
also slightly carried backward. 3 I have twice also met with examples in which 
the posterior fragments were inclined to fall inward toward the mouth, a circum- 
stance which seemed to indicate that the course of the obliquity was in a direc- 
tion opposite to that which Malgaigne has observed to be most frequent. In 
each of these examples the jaw was broken upon both sides, by blows inflicted 

1 New York Journ. of Med., Oct. 1840. Hospital Reports. 2 Malgaigne. 

3 Trans. Amer. Med. Assoc, vol. viii. p. 380, 1855, Case 6. 



11.4 FRACTURES OF THE LOWER JAW. 

with a club, and the fractures were situated well back. 1 It is possible, however, 
that the position of the fragments was due rather to the direction and force of 
the impression than to the direction of the line of fracture. 

The digastricus, the genio-hyoglossus, and the mylo-hyoideus, with 
several other muscles which act less directly, all tend to depress the an- 
terior fragment, and in some slight degree to carry it backward ; a direc- 
tion which, indeed, it usually takes, and which it would probably always 
take if left alone to the action of the muscles. If the fracture has 
occurred through the angle, or at any point within the attachments of 
the masseter muscle, the action of those fibres of this muscle which 
remain connected with the anterior fragment will sufficiently explain the 
fact that it is not now so easily depressed below the level of the posterior 
fragment ; whilst the separation of the fragments along the line of the 
base, when an attempt is made to close the jaw forcibly, is probably due 
to the loosening and partial dislodgment of some of the molars, which, 
being pressed upward, act as a pivot upon which the fragments are made 
to bend. 

An overlapping of the fragments in the direction of the axis is, in 
simple fractures, no doubt, exceptional, and in such examples as I have 
seen it was very trivial. 

It occurred in case "three "of my ''Report," the fracture being near the 
mental foramen ; in case " two," the fracture being just anterior to the last 
molar; and also in case "six," where the bone had been broken through the 
centre of the body on both sides and through the symphysis ; but in neither case 
did the overlapping exceed two or three lines, and it was always easily over- 
come. 

The mobility of the fragments is not so striking in these accidents as 
in fractures of the long bones, yet it is generally sufficiently marked, and 
especially where the bone is broken upon both sides at the same time. 
If only one side is broken, both motion and crepitus will be most easily 
detected by lateral pressure upon the posterior fragment, which, being 
the smallest and the least supported by antagonizing muscles, will be 
found to be the most movable. If the fracture is upon both sides, 
mobility and crepitus will be most readily developed by seizing upon the 
anterior fragment and moving it gently up and down, while the finger 
rests upon the alveolus within the mouth. Sometimes a slight swelling 
or tenderness at some point of the dental arcade, or the loosening or 
complete dislodgement of a tooth, will indicate the point of fracture. 
Pain, especially when the fragments are moved, is here more constant 
than in most other fractures, owing perhaps, in part, to the superficial 
position of the bone, which renders the soft parts lying over it more liable 
to injury from the causes of fracture ; but also, in part, to the lesion 
which the inferior dental nerve may have suffered. 

It is, indeed, a matter of surprise that injury to this nerve does not oftener 
seriously complicate these accidents, coursing, as it does, through so large a 
portion of the angle and body of the bone. One might naturally suppose that 
its complete disruption would often occasion paralysis of those portions of the 
face to which it is finally distributed, and that its partial lesions and contusions 

1 Ibid., Cases 1 and 10. 



FRACTURES OF THE LOWER JAW. 115 

would create, in many cases, the most acute and constant suffering. It is rare, 
however, that we have present an amount of pain which might not be attributed 
to a severe shock, or a slight strain upon its fibres. I have myself never seen 
any extraordinary suffering directly attributable to an injury of the dental nerve 
after fracture ; nor any degree of facial paralysis, except in the case to be here- 
after described. Rossi relates a case in which convulsions followed this acci- 
dent, and in which, as a final remedy, he proposed to expose and bisect the 
nerve ; and Flajani saw a patient, whose jaw had been broken, die in convul- 
sions on the tenth day, the muscular contractions having commenced as early as 
the fourth day after the accident. The autopsy disclosed a rupture of the dental 
nerve, but no injury to the brain. 

If the displacement is sufficient to occasion a complete disruption of 
the nerve, some degree of temporary paralysis in the portions of the face 
supplied by it must be inevitable ; and, perhaps this occurs oftener than 
it has been noticed, since, during the confinement of the jaw by dressings, 
it is not likely to be observed, and after the lapse of a few weeks it will 
probably cease altogether. A single case in which the paralysis was 
reported by Desirabode. 1 

Berard mentions a case of vertical fracture occurring between the second and 
third molars, without displacement, which was accompanied with complete 
insensibility of the lip on the same side throughout the space comprised between 
the commissure and the median line, and between the free border of the lip and 
the chin. The paralysis disappeared after a few days. 2 

Dr. F. S. Dennis remarks that hemorrhage into the dental canal, or a slight 
laceration of the inferior dental nerve, with little displacement of the fragments, 
may cause a paralysis, which, in the former case after absorption, and in the 
latter case after repair of nerve-tissues, eventually terminates in complete 
recovery. 

[Spencer, of London, reports a case of fracture between the first and. second 
molar teeth followed by ansesthesia over an area bounded by a line drawn verti- 
cally from the angle of the mouth and the middle line, and from the border of 
the lip to the lower margin of the jaw. The nerve in this case seems to have 
been torn. 3 ] 

To these signs now enumerated, we may add, as occasional complica- 
tions rather than as diagnostic symptoms, salivation, swelling of the 
submaxillary and sublingual glands, abscesses, necrosis, etc. If the blow 
has been vertical upon the chin, and the direction of its force has been 
toward the articulations, the bony structure of the ear, and even the 
brain, may have suffered serious lesions, which may be indicated by a 
deafness or a roaring in the ears, by bleeding from the external meatus, 
and by fatal coma. 

Tessier saw a man who had received the kick of a horse exactly upon the 
centre of the chin, breaking the bone on both sides, and who, in consequence, 
bled freely from his ears ; 4 and Alix relates the case of a young man who, falling 
from a height and striking upon his chin, had broken his jaw. Insensibility 
immediately followed; convulsions also ensued upon the fourth day, and he 
died upon the sixth. 5 

If the fracture is at the symphysis, it is generally vertical, and either 
fragment may be found slightly displaced upward or downward. 

1 Journ. des Connaissances, 1857, ISTo. 20, p. 538. 

2 Malgaigne, from Gazette des Hopitaux, 10 Aout, 1841. 

3 Tr. Lond. Path. Soc, 1888, vol. xxxix. 

i Malgaigne, pp. 383 and 386, from Journ. de Med., 1789, torn, lxxix. p. 246. 
5 Ibid., p. 386, from Alix, Observata Chir., fascic. 1, obs. 10. 



116 FRACTURES OF THE LOWER JAW. 

In one of the examples seen by myself, the left fragment fell three lines below 
the right, and in another the right side had fallen about one line. In a case 
mentioned by Syme there was scarcely any displacement. 1 Liston remarks that 
it is usually slight. 

The signs which indicate a fracture through the angle have already 
been sufficiently considered when speaking of fractures of the body ; from 
which it only differs in the less degree of displacement, and in the fact 
that the posterior fragments are a little more prone to fall inward 
toward the mouth. Owing probably to the loosening and partial dis- 
lodgment of the last molar, it is sometimes difficult to close the mouth, 
the same as in fractures a little further forward. 

In two examples of fracture of the ascending ramus, the bone being 
broken also through its body, the fracture of the ramus was recognized 
by both crepitus and mobility. 

The signs which indicate a fracture of the coronoid process are inferred 
from its anatomical relations. There must be some embarrassment in 
the motions of the jaw, occasioned by the detachment of a portion of the 
fibres of the temporal muscle ; and it is probable that an examination 
by the finger within the mouth would readily detect mobility and dis- 
placement. 

A fracture through the neck of the condyle is characterized by pain 
at the seat of fracture, especially recognized when an attempt is made to 
open or shut the mouth, by embarrassment in the motions of the jaw, by 
crepitus, which may usually be felt or heard by the patient himself, by 
mobility and displacement. The upper fragment, if disengaged from the 
lower, is drawn forward, toward, and inward, by the action of the ptery- 
goideus externus ; and is felt not to accompany the movements of the 
lower fragment. 

The lower fragment is at the same time drawn upward, in consequence 
of which the lower part of the face is distorted ; a circumstance first 
noticed by Ribes, and which supplies an important diagnostic mark 
between a fracture of one condyle and a dislocation. In dislocation the 
chin is commonly thrown to one side, but it is to the side opposite that 
on which the dislocation has occurred, while in fracture the chin is drawn 
to the same side. 

Prognosis. — In no instance of a simple fracture which has come under 
my personal care from the first, has the bone refused kindly to unite, 
although I have seen the union delayed six, seven, ten, and even eleven 
weeks or more. 2 In three of these cases the fractures were either com- 
pound or comminuted ; but in one case the fracture was simple, the delay 
in union being due to a feeble condition of the system, and in part, 
perhaps, to neglect of proper treatment. Since the commencement of 
the late war I have met with several examples of non-union, and of 
fibrous union, after gunshot fractures ; but, so far as I can remember, in 
all of these cases necrosis existed, or some portions of the bone had been 
carried away. 

The infrequency of non-union after this fracture is a fact worthy of 
especial attention, because of the extreme difficulty, if not actual impos- 

1 Amer. Journ. Med. Sci., vol. xviii. p. 243. 

2 My Report on Deformities after Fractures, Cases 2, 14, 15, 18. 



FRACTURES OF THE LOWER JAW. 117 

sibility, in many cases, of wholly preventing motion between the frag- 
ments, by any mode of dressing yet devised. Anyone who has observed 
attentively, must have seen, not only that his dressings are more often 
found disturbed and loosened than in the case of almost any other frac- 
ture, unless it be the clavicle, and thus the fragments have been through 
all the treatment subjected to frequent changes of position; but, also, 
that even while the dressings remain snugly in place, the patient seldom 
is able to perform the necessary acts of deglutition, so to speak, even 
without inflicting some slight motion upon the fragments. 

Indeed, the rapidity as well as certainty with which this bones unites, 
has, I think, been observed by other surgeons, and I have m} r self noticed 
one instance, in an adult person, in which the bone was immovable at 
the seat of fracture on the seventeenth day, and perhaps earlier. In other 
instances the union has been speedily effected after the removal of all 
dressings. 

Physick, of Philadelphia, saw a case of non-union of the body of this bone 
which had existed nine months. 1 Dupuytren mentions a case which had existed 
three years. 2 Stephen Smith, of New York, reports a case of fracture of both 
the body and the ramus, in a man forty-five years old. The severity of the 
injury, with the supervention of delirium tremens, prevented the application of 
dressings until the thirteenth day. On the twentieth day about a pint of blood 
was lost by hemorrhage from the seat of fracture. He remained in the hospital 
one hundred and thirty-seven days, and was finally discharged, the fragments 
not having yet united. 3 I have seen four examples of fibrous union. In Dr. 
Muhlenberg's tables 16 examples are enumerated out of a total of 656 cases of 
non-union and delayed union. 4 

The amount of deformity resulting, also, from these fractures is usually 
very trifling, whatever treatment has been adopted. Only nine of the 
united fractures, seen and recorded by me, are imperfect, and in none of 
these is the imperfection such as to be noticed in a casual examination of 
the face. The deformity which is usually found, is a slight irregularity 
of the teeth, produced, in most cases, by a falling of the anterior frag- 
ment, but in one case by a slight elevation of the anterior fragment. But 
even this does not always interfere with mastication, and would often 
pass unnoticed by the patient himself. It is probable, too, that time, 
and the constant use of the lower jaw in mastication, will gradually effect 
a marked improvement in the ability to bring the opposing teeth into 
contact. 

Packard, of Philadelphia, informs me that in a case of fracture of the lower 
jaw, occurring near the left anterior mental foramen, the right fragment was so 
forcibly displaced downward, by the action of the muscles, that he was obliged 
to sever their attachments at the symphysis, in order to retain the fragments in 
place. In the second example of fracture through the symphysis mentioned by 
me, the left fragment remained slightly elevated, and the patient could not close 
his teeth perfectly, yet he could close them sufficiently for the purposes of masti- 
cation. It is probable, however, that ordinarily no difficulty will be experienced 
in accomplishing a perfect cure when the separation has taken place only at the 
symphysis. 

1 Phila. Med. and Surg. Journ., vol. v. 2 Lemons Orales. 

3 Smith. Xew York Journ. of Med. and Surg., Jan. 1857. 

4 Agnew's Surg., op. eit., vol. i. p. 804. 



118 FKACTUKES OF THE LOWER JAW. 

In fractures of the condyles more care is requisite to retain the frag- 
ments in apposition, and sometimes it may be found to be impossible. 

Bicherand mentions the case of a man, who, having been three months in the 
Hopital de la Charite for a double fracture of the lower jaw, the fracture being 
near the middle, and the other near the right condyle, left before the cure was 
complete. Seven or eight months after, he called upon Boyer, who extracted, 
from a fistula in the meatus auditorius externus, a bony mass which had evi- 
dently the form of the condyle. 1 Bichat mentions a similar case as having come 
under the observation of Desault. 2 Bibes says that a Parisian surgeon treated 
a double fracture of the jaw in a gentleman, one fracture being through the body 
and the other through the neck of the condyle; and, in spite of the most assid- 
uous and skilful attention, the patient recovered with a lateral distortion of the 
jaw, occasioned by the displacement of the fragments. 3 Bibes himself had to 
treat an accident of a similar character, and, notwithstanding all his care, the 
result was the same as in the other example just cited. 4 

The proximity of this fracture to the articulating surface may occasion 
contraction of the ligaments about the joint ; and a degree of embarrass- 
ment to the motions of the jaw has followed in the experience of Desault 
and others, even when the cure has been most complete ; but this has 
usually remained only for a short period. 

Sanson asserts that when the coronoid process is broken, the fracture never 
unites ; but that mastication is performed very well, the masseter and pterygoid 
muscles then fulfilling the office of the temporal. 5 

Treatment. — The few attempts which I have made to restore a com- 
pletely dislocated tooth to its socket, or to retain it in place when very 
much loosened, have generally resulted in its removal at some later day, 
and especially where the fracture has been near the angle and a molar 
has been disturbed. I believe it would be better practice always to 
remove the molars under these circumstances, unless they remain attached 
to the alveoli, and cannot be removed without bringing them aw r ay also; 
and this, whether the loosened teeth are situated in the line of fracture 
or not. It is seldom that they can be made again to occupy their sockets 
perfectly, and where the teeth are in the line of the fracture, the attempt 
to restore them to place will sometimes prevent the proper adjustment of 
the fragments. In cases, also, in which the teeth further forward are 
completely dislodged at the seat of fracture, it is scarcely worth while to 
replace them. As to those teeth whose loosened condition is due only to 
a splitting of the alveoli in a longitudinal direction, the same rule will 
not always apply. Sometimes, after a careful readjustment, the frag- 
ments will reunite, and the teeth remain firm. 

If the bone is chipped off upon the outside, through or near the line 
of the sockets, the teeth may be not always much disturbed, and the loss 
of the fragments may be of less consequence, nor have I generally suc- 
ceeded in saving them ; yet, if they remain adherent to the soft parts, it 
is proper to make the attempt. The expedients to which surgeons have 
resorted for the purpose of retaining in place the fragments, when the 

1 Boyer, Lectures on Dis. of Bones, p. 53, Phila. ed., 1805. 

2 Desault, Treatise on Fractures and Luxations, Phila. ed., 1805, p. 3. 

3 Malgaigne, op. cit., p. 402. 4 Ibid., p. 402. 
5 S. Cooper's First Lines, Amer. ed., 1844, vol. ii. p. 311. 



FRACTURES OF THE LOWER JAW. 119 

bone is broken through its body, may be arranged under the names of 
ligatures, splints, bandages, and slings. 

The ligature has been applied both to the teeth and to the bone itself. 

Thus, in an oblique fracture near the angle, where the fragments could not 
otherwise be prevented from falling inward, Baudens passed a strong ligature, 
formed of thread, around the fragments and in immediate contact with them, 
tying the ligature over the teeth within the mouth. No accident followed, and 
on the twenty-third day, when he removed the ligature, the bone had united 
firmly and smoothly. 1 

Picharel and Berenger-F6raud have successively practised the same method 
in certain very oblique fractures of this bone, where it seemed impracticable to 
employ other means. 2 

In most cases, however, the ligature, when applied directly to the bone, 
has been employed as a suture, in the form of metallic wire. 

In Dr. Buck's case the bone was broken between the two incisor teeth of the 
left side ; the part of the bone on the left of the fracture was driven in, and 
interlocked behind the end of the right portion, so as to be separated by a finger's 
breadth. Finding it impossible otherwise to reduce the fracture, he dissected 
off the under lip, so as to expose the fracture ; the right anterior portion of the 
fractured bone terminated in an angular projection as far as on a line below the 
left angle of the mouth ; the lip was then divided to the chin, and the soft parts 
holding the fragments together incised ; a chisel was then insinuated behind the 
projecting angle of the bone, while it was being excised by the metacarpal saw. 
When the bone was restored to its natural position, it was found so apt to become 
displaced that holes were drilled at the lower angle of the fracture, and adjustment 
maintained by wiring them together, the wire passing out through the lower 
angle of the wound. Sutures and adhesive straps, with a bandage, were em- 
ployed to maintain the adjustment of the parts. 3 Dr. R. A. Kinloch, of Charles- 
ton, S. C, has reported a similar case, in which he employed successfully the 
wire. 4 

While trephining at the angle of the jaw for the purpose of cutting out a por- 
tion of the dental nerve I accidentally broke the jaw at the point at which the 
trephine was applied. I immediately bored a hole in the opposite extremities 
of the two fragments, and fastened them together with a silver wire, by which I 
was able to maintain complete apposition, and in three weeks the union was 
accomplished, the wire separating and falling out of itself. No splints were 
ever used. 5 

A fracture of the inferior maxilla between the second bicuspid and second 
molar united with a fibrous band, and with a good deal of displacement. I 
operated, by making an external incision to the point of fracture, exposing the 
bone thoroughly, and, having freshened the broken surfaces, the fragments were 
perforated and secured in apposition with a silver wire, and a bony union was 
effected with but little displacement. 

The perforations must be made perpendicularly, not obliquely through 
the fragments, and some distance from their margins. To withdraw the 
wire or to return it from within outward, an instrument with a straight 
shaft, rather smaller than the perforation, and furnished with an abruptly 
curved, blunt extremity, is required. The wire should be large, strong, 
and flexible, and the perforation should be twice as large as the w T ire. 

1 Malgaigne, op. cit., p. 398. 

2 Berenger-Feraud, Traite de Immobilization direct. Paris, 1870. (Poinsot.) 

3 New York Journ. of Med., etc., March, 1847, p. 211. 

4 Kinloch, Amer. Journ. Med. Sci., July, 1859, p. 67. 

5 Buffalo Med. Journ., xiv. p. 148. 



120 



FRACTURES OF THE LOWER JAW 



[In compound fractures of the lower jaw, Thomas, of Liverpool, drills the 
bones on each side of the fracture, and fixes the fragments by means of thick, 
pliant silver wire. He coils the wire on each side with a key. (Figs. 36, 37, 
38, and 39.)] 

Ordinarily the ligature has been employed only as a means of reten- 
tion, by fastening it upon the teeth, either upon those which are situated 



Fig. 36. 



Fig. 37. 




Thomas's first method of uniting fracture of the lower jaw; A, B, wires passed 
through drill-holes and coiled by the key. 



Fig. 38. 



Fig. 3 




Thomas's second method of uniting fracture of the lower jaw by twisted 
and coiled wire. 



on the opposite sides of the fracture, or upon others a little more remote, 
or upon the corresponding teeth of the upper jaw, or upon the teeth, on 
the opposite side of the same jaw. In most cases the ligature, composed 
of either fine gold, platinum, or silver wire, or firm silk or linen threads, 
has been applied to the two teeth on the opposite sides of the fracture, 
or, if these have not been sufficiently firm, to the next teeth. 

Dr. Ellis, of New York, treated a fracture, occurring through the symphysis, 
by placing the mainspring of a watch within the dental arcade, arid securing it 



FRACTURES OF THE LOWER JAW. 121 

in place with silver wire. The mouth was kept closed by bandages carried 
under the chin. The fragments united with only a slight vertical displacement. 1 
Dr. Hayward, of Boston, says : When the bone is not comminuted and there are 
teeth on each side of the fracture, the ends of the bone can be kept in exact appo- 
sition by passing a silver wire or strong thread around these teeth, and tying it 
tightly. I have myself in two or three instances used a linen thread with 
excellent results. 

[Dr. Brown, 2 of Minneapolis, has employed what is styled the anchor splint, 
originally used by Dr. Angle, a dentist of that city, to correct deformities of the 
teeth. Two or more firm teeth are selected on either side of the fracture and 
carefully banded with German silver made into a loop and slipped over the 
teeth ; the band is caught by pliers and drawn tightly about the teeth ; the 
bands are now removed, the ends clipped off and soldered, and again applied to 
the teeth, and hollow tubing or joint wire is placed against the bands, one on 
each side of the line of fracture, and marked at the point of contact. The 
bands are again removed, and the pipes are soldered to them. A traction screwt 
made of hard-drawn German silver, is passed through the tubes and the nu, 
started. A rubber drain is next applied to the teeth to keep them thoroughly 
dry, and the appliance slipped over the teeth and cemented in place by oxy- 
phosphate of zinc. After this thoroughly sets the nut is tightened until the 
ends of bone are in place. This apparatus must be useful where the teeth are 
well set.] 

None of these various methods, however, will in general be found to 
possess much value ; for besides that they are all of them, in a large 
majority of cases, wholly unnecessary, and in other cases, owing to the 
absence of the teeth, or to their loosened or decayed condition, or to the 
closeness with which they are set against each other, absolutely imprac- 
ticable, it must be seen, also, that they will generally prove feeble and 
inefficient. The wires act only upon the upper extremity of the line of 
fracture, leaving its lower portion liable to be disturbed by trivial causes ; 
they tend gradually to loosen even the firm teeth which they embrace, 
and not unfrequently, after having been made fast with much labor, they 
soon become disarranged or break. They require, therefore, almost 
always the additional protection afforded by bandages, interdental splints, 
etc. Alone they are usually insufficient, and if properly constructed 
bandages, slings, interdental splints, etc., are employed, they are not 
needed. Sometimes, moreover, they are actually mischievous, as when 
they loosen a sound tooth or press upon and inflame the gums. 

Splints have been employed in various ways. First, simply inter- 
dental splints, laid along the crowns of the teeth, and only sufficiently 
grooved to be easily retained in place ; second, clasps, which are applied 
over the crowns and sides of the teeth, operating chiefly by their lateral 
pressure, or made fast by screws ; third, splints applied to the outer and 
inferior margin of the jaAv ; fourth, interdental splints combined with 
outside splints. Interdental splints have been recommended by many 
surgeons from an early day, and they continue to be employed occasion- 
ally up to this moment. 

The objections which have been stated to their use are : that they are 
unsteady and become easily loosened and disarranged ; that they occa- 
sionally press painfully upon the inside of the cheeks ; that they accu- 

1 Trans. Amer. Med. Assoc, vol. viii. p. 383. Mv Report on "' Defor.." etc., Case 14. 

2 Med. Record, Oct, 6, 1888.' 



122 FRACTURES OF THE LOWER JAW. 

mulate about themselves an offensive sordes ; and finally that they are 
unnecessary. Their great purpose is to act as splints whenever the 
absence of teeth, either in the upper or lower jaw, renders the two cor- 
responding arcades unequal and irregular, and prevents our making use 
of the upper as a kind of internal splint for the lower jaw. Many of 
the inconveniences which have been found to attend the use of cork or 
wood, are obviated by the substitution of gutta-percha. 

The mode of preparing gutta-percha, and of adapting it between the teeth, is 
as follows : Dip a couple of pieces of the gum, of a proper size, into hot water ; 
and when they are softened, mould them into wedge-shaped blocks, and carry 
them to their appropriate places between the back teeth on each side of the 
mouth ; taking care, of course, that on the fractured side the splint extends 
sufficiently far forward to traverse thoroughly the line of fracture. Now press 
up each horizontal ramus of the jaw until the mouth is sufficiently closed, and 
the line of the inferior margin is straight ; in this position retain the fragments 
a few minutes, until the gum has well hardened. Meantime it will be prac- 
ticable, generally, to introduce the fingers into the mouth, and to press the gutta- 
percha laterally on each side toward the teeth, and thus to make its position 
more secure. When it is hardened remove the splints, lor the purpose of deter- 
mining more precisely that they are properly shaped and fitted. In carrying 
the long wedge-shaped block into the mouth, the apex of the wedge is to be 
introduced first. If properly made, it is smooth upon its surface, and not, there- 
fore, so liable to irritate the mouth as wood or cork, and it is so moulded to the 
teeth that it will never become displaced. It possesses this advantage, also, that 
in case more or less of the teeth are gone in either the upper or lower jaw, it 
fills up the vacancies, and renders the support uniform and steady. 

The "clasp," applied over the crowns and sides of teeth, is not in- 
tended to act as an interdental splint ; but by its lateral pressure it is 
expected to hold the fragments in apposition upon nearly the same prin- 
ciple with the ligature. 

Mutter, of Philadelphia, and N. R. Smith, of Baltimore, employed for this 
purpose a plate of silver, folded snugly over the tops and sides of two or more 
teeth adjacent to the fracture. Nicole, of Neubourg, employed for the same 
purpose a couple of steel plates fitted accurately along the anterior and posterior 
dental curvatures, secured in place by a steel clasp, furnished with a thumb- 
screw, in order the more effectually to accomplish the lateral pressure. 

Malgaigne substituted a single plate composed of flexible and ductile iron, 
which is fitted accurately to all the irregularities of the posterior dental arch. 
From the two extremities of this plate, and from two other intermediate points, 
four small steel shafts arise perpendicularly, cross the crowns of the teeth at 
right angles, and then fall down again perpendicularly upon the anterior dental 
arcade. Each steel shaft being furnished with a thumb-screw, the iron plate 
can now be made to bear against the teeth so as to form a posterior dental splint. 
The teeth are also protected in front against the direct action of the thumb- 
screw by the interposition of a leaden plate. J. B. Gunning, dentist, of New 
York, substituted vulcanized India-rubber, which he employs both as a clasp and 
an interdental splint. Dr. Covey 1 states that the same material has been used 
with excellent results by J. B. Bean, dentist, of Atlanta, Ga., as follows : An 
impression is taken in wax of the crowns of the teeth of the uninjured jaw, and 
of each fragment separately of the broken jaw. " From these impressions are 
made casts of plaster-of-Paris, very carefully prepared, so as to produce a smooth, 
hard surface, and giving as perfect a representation of the teeth as possible. 
These plaster models are then adjusted, properly antagonized in their normal posi- 
tion, and placed in the ' maxillary articulator.' (Fig. 40.) The fragments of the 
model representing the broken jaw are held in their proper position by wax, being 

1 Bean, Richmond Med. Journ., Feb. 1866. 



FRACTURES OF THE LOWER JAW. 



123 



secured thus one to the other, and to the remaining plate of the articulator." 
. . . . The model jaws are now opened from three to five lines, and a wax 
model of a splint is built up between the molars, covering also the inner and 



Fig. 40. 



Fig. 41. 




Maxillary Articulator. 

1, 1. Upper and lower plates. 

2, 2. Adjustable rods. 
3,3. Adjustable hinge. 




Bean's apparatus for broken jaw, applied. 



outer surfaces of the teeth. A connecting band of wax is laid from one side to 
the other behind the upper front teeth, leaving thus an opening in front for the 
reception of food. This wax and plaster model, now composing one piece, is 
then removed from the articulator, and placed in a dentist's " flask,'' and a com- 
plete mould of the model is again formed from plaster laid on in sections, in a 
manner which those accustomed to make plaster moulds will readily understand. 
The plaster having fairly set, the flask and mould are opened, Ihe wax care- 
fully removed, and the spaces thus left in the mould at once filled with the 
rubber rendered soft by heat. The mould is again closed, replaced in the flask, 
and by heat the rubber is thoroughly vulcanized. The flask is again opened, 
the plaster removed, and an interdental splint of rubber remains, which is fitted 
accurately to all the surfaces of the teeth both above and below. The splint is 
now placed in the mouth, adjusted to the teeth, and the lower jaw secured in 
position by the apparatus represented in Fig. 41. 

[An interdental splint, invented by Mr. G. E. Hammond, has, according to 
Jacobson, replaced wiring the fragments at Guy's Hospital. Pick also regards 
it as the most satisfactory interdental 

splint of the various forms in use. "The Fig. 42. 

splint consists of a framework or collar 
of iron, which is adapted to the frac- 
tured jaw, encircling the necks of the 
teeth, and to it they are fastened with 
loops of iron wire. The essential point 
in the application of the splint is that 
the collar of iron wire should accurately 
fit the outline of the jaw, so that it shall 
remain in the position in which it is 
placed ; otherwise it will probably de- 
feat the object for which it is intended. 
In order, therefore, to frame it, it is 
necessary to take a cast of the teeth, on 
which to model the collar. . . . When 
moulded it will present somewhat the 
outline represented in Fig. 42: The 
collar is to be applied to the teeth of the patient, and fixed, in the manner 
shown in the diagram, by several pieces of fine, soft wire, the wire being never 




Hammond's splint. 



124 



FRACTURES OF THE LOWER JAW. 



carried more than one tooth. The wires on each side of the mouth are twisted 
alternately, and the twisted ends are cut short and turned down under the iron 
framework, so as to prevent their sticking into or injuring the mucous mem- 
brane." The figure shows the collar of metal moulded to fit the teeth of the 
lower jaw, and the manner of tying the teeth to the metal collar. 1 

Nevvland-Pedley, dental surgeon to St. Thomas's Hospital, London, has 
recently employed Gunning's dressing with much success. In multiple fractures 
of the body of the jaw it furnishes a uniform support scarcely secured by any 
other dressing.] 

Dr. J. S. Prout, of Brooklyn, has suggested a mode of employing the inter- 
dental splint and wire ligature conjointly. A plate of gutta-percha was placed 
upon the top of the teeth across the line of fracture, and this was secured in 
position by silver wire, which had been made to grasp firmly the crowns of the 
adjacent teeth, and w r as then brought over the horizontal gutta-percha plate. It 
accomplished all that was desired. 

External splints, applied along the base or outside of the jaw, were 
first recommended by Pare, who used for this purpose leather ; and they 
have be:n employed in some form, occasionally, by most surgeons. 
Generally they have been composed of flexible materials, such as wetted 
pasteboard, first recommended by Heister, felt, linen saturated with the 
whites of eggs, paste, dextrine, or starch ; plaster-of- Paris has also been 
used ; and they have been retained in place by either bandages or the 
sling. Undoubtedly useful, and even necessary in some cases, especially 
where there exists a great tendency to a vertical displacement, they will 
be found, also, in many cases, to render no essential service, and may 
properly enough be dispensed with. 

[J. W. Cousins, surgeon to the Portsmouth Hospital, applies an apparatus 
which consists of a steel splint encircling the neck, being horseshoe- shaped, and 
the ends on either side terminate in a loop which supports a movable pad, the 
pressure of which is regulated by a screw ; a webbing extends from loop to loop 
under the chin, and another passes from side to side over the forehead and is 
supported by a central strap attached behind to the splint. This splint is 
recommended in severe cases, as in multiple fracture. 2 ] 

Whatever objections hold to the use of metallic clasps, must apply in some 
degree to the use of those forms of apparatus in which it is attempted to secure 
the fragments by means of a combination of these clasps with outside splints, 

and in which it is proposed to dispense 
with all bandages or slings, the mouth 
being permitted to open and close 
freely during the whole treatment. 
Motion of the jaw cannot be permitted 
in any case where the fracture is far 
back, since it is then impossible to 
grasp the posterior fragment between 
the two parallel splints. Nothing but 
complete immobility of the jaw will 
now insure immobility to the fracture. 
If I were to recommend any form 
of apparatus constructed with a view 
of permitting mobility of the jaws dur- 
ing the process of union, it would be 
that invented by Kingsley, dentist, of 



Fig. 43. 




Plaster model of jaws. 



New York. Impressions in plaster are first taken of both upper and lower jaws. 
Models made from these impressions will represent the lower jaw broken and 
the fragments displaced. The model of the lower jaw is then separated at the 
point representing the fracture, and the fragments adjusted to the model of the 



1 Pick, Fract. and Disloc. 



2 London Lancet, Sept. 29, 1888. 



FRACTURES OF THE LOWER JAW. 



125 



upper jaw. In most cases the position which these fragments assume when 
thus placed determines accurately the original form and position of the lower 
jaw. Upon the plaster model of the lower jaw, obtained and rectified in this 



Fig. 44. 




Kingsley's apparatus applied to model. (From Kixgsley.) 

way, a splint or clasp of vulcanite rubber is then made, embracing the arms, 
which are made of steel wire, one-sixteenth of an inch in diameter. The arms 



Fig. 45. 



Fig. 46. 




Kingsley's apparatus applied to patient. 
(From Kingsley.) 




Gibson's bandage for a fractured jaw. 



must curve upward a little as they emerge from the mouth, to avoid pressure 
upon the lips, and then curve backward, terminating near the angles of the 
jaw. When the apparatus is applied, the teeth must be pushed into the sockets 



126 



FRACTURES OF THE LOWER JAW. 



of the splint with some force. The dressing is now completed by a sling made 
of strong muslin, extending beneath the chin from one arm to the other. 

The treatment of fractures of the inferior maxilla by a single-headed 
bandage or roller, numbers among its distinguished advocates the names 
of William Gibson and J. Rhea Barton, of Philadelphia. 

Gibson gives the following directions for applying his roller : " A cotton or 
linen compress, of moderate thickness, reaching from the angle of the jaw nearly 
to the chin, is placed beneath, and held by an assistant, while the surgeon takes 
a roller, four or five yards long, an inch and a half wide, and passes it by several 
successive turns under the jaw, up along the sides of the face, and over the 
head ; now changing the course of the bandage, he causes it to pass off at a right 
angle from the perpendicular cast, and to encircle the temple, occiput, and 
forehead, horizontally, by several turns; finally, to render the whole more 
secure, several additional horizontal turns are made around the back of the 
neck, under the ear, along the base of the jaw, under the point of the chin. To 
prevent the roller from slipping or changing its position, a short piece may be 
secured by a pin to the horizontal turn that encircles the forehead, and passed 
backward along the centre of the head as far as the neck, where it must be 
tacked to the lower horizontal turn — taking care to fix one or more pins at every 
point at which the roller has crossed." 



Fig. 47. 



Fig. 48. 





Barton's bandage for a fractured jaw. 



Garretson's bandage. 



Barton employed, also, a compress, and a roller five yards long, the application 
of which is thus described by Sargent : Place the initial extremity of the roller 
upon the occiput, just below its protuberance, and conduct the cylinder obliquely 
over the centre of the left parietal bone to the top of the head ; thence 
descend across the right temple and the zygomatic arch, and pass beneath 
the chin to the left side of the face ; mount over the left zygoma and temple to 
the summit of the cranium, and regain the starting-point at the occiput by 
traversing obliquely the right parietal bone ; next wind around the base of the 
lower jaw on the left side to the chin, and thence return to the occiput along the 
right side of the maxilla; repeat the same course, step by step, until the roller 
is spent, and then confine its terminal end. 

These bandages possess the advantages of being easily obtained, of 
simplicity and facility of application, and, we may add, if considered in 
relation to the majority of simple fractures, of tolerable adaptation to 
the ends proposed. The only objections to their use which I have ever 
noticed are occasional disarrangements, and the tendency, as in all other 



FRACTURES OF THE LOWER JAW, 



127 



continuous rollers, to draw the fragments to one side or the other, accord- 
ing as the successive turns of the bandage are carried to the right or left. 
There is one other objection, having reference to the occasional inade- 
quacy of this dressing to prevent an overlapping of the fragments ; to 
which objection also the sling, as usually constructed, is equally obnoxious, 
and of which I shall speak presently. 

Fig. 50. 





Four-tailed bandage or sling for the lower jaw. Gutta-percha or pasteboard splint applied. 

Finally, it is to the sling, in some of its various forms, with or without 
the interdental splint, that surgeons have generally given the preference. 
The sling is known, also, by the name of the four-headed or the four- 
tailed roller or bandage. The favorite mode is to use for this purpose a 
piece of muslin cloth about one yard long and four inches wide, torn 
down from its extremities to within about three or four inches of the 
centre. Others have used leather, gutta-percha, adhesive straps, gum- 
elastic, etc. 



Fig. 51. 



Fig. 52. 



i -_ - ,— . 








Gutta-percha cut into proper shape for splint. 




Gutta-percha folded for splint. 



[Pick [Fractures and Dislocations) very correctly advises to avoid the splint, if 
iible, for it is uncomfortable to the patient from retaining perspiration, and 
often becomes dirty and sodden from the dribbling of the saliva, and if there is 
any bruising or injury of the soft parts may, by the pressure which it causes, 
produce suppuration. The gutta-percha and pasteboard are cut and folded as 
seen in Figs. 51 and 52.] 



128 



FRACTURES OF THE LOWER JAW 



Where the muslin is used, it is quite customary to lay against the skin 
a piece of pasteboard, wetted and moulded to the chin, or simply a soft 
compress ; and some choose to open the centre of the bandage sufficiently 
to receive the chin. The middle of this bandage being laid upon the 
chin, the two ends corresponding to the upper margin of the roller are 
now carried across the front of the chin, behind the nape of the neck, 
and made fast ; whilst the two lower heads are brought directly upward 
from under the sides of the chin, along the sides of the face, in front of 
the ears, and made fast upon the top of the head. The dressing is com- 
pleted by a short counter-band extending across the top of the head from 
one bandage to the other ; or the several bands may be made fast to a 
night-cap, in which case the counter-band will be unnecessary. 

Having frequently noticed the tendency of the sling, as ordinarily con- 
structed, and of Gibson's roller, to carry the anterior fragment backward, 
especially in double fracture where the body of the bone is broken upon 
both sides, I devised an apparatus intended to obviate this objection, and 
which I have used now many times with entire satisfaction. 

[Pick {Fractures and Dislocations) states that the reason this backward disloca- 
tion occurs is because surgeons are wont to recommend that the upper strand of 

the bandage should be tied around the nape 
F IG , 53. of the neck. This has a tendency to pull 

the anterior fragment directly backward, but 
if the bandage is applied as is shown in Fig. 
53 this displacement will not occur.] 

It is composed of a firm leather strap, 
called maxillary, which, passing perpen- 
dicularly upward from under the chin, is 
made to buckle upon the top of the head, 
at a point near the situation of the an- 
terior fontanelle. This strap is supported 
by two counter- straps, made of strong 
linen webbing, called, respectively, the 
occipitofrontal and the vertical. The 
occipito-frontal is looped upon the maxil- 
lary at a point a little above the ears, 
and may be elevated or depressed at 
pleasure. The occipital portion of the 
strap is then carried backward, and 
buckled under the occiput, while the 
frontal portion is buckled across the fore- 
head. The vertical strap unites the 
occipital to the maxillary across the top of the head, and prevents the 
upper part of the latter from becoming displaced forward. At each 
point where a buckle is used, a pad must be placed between the strap 
and the head. The maxillary strap is narrow under the chin, to avoid 
pressure upon the front of the neck, but immediately becomes wider, so 
as to cover the sides of the inferior maxilla and face, after which it 
gradually diminishes, to accommodate the buckle upon the top of the 
head. The anterior margin of this band, at the point corresponding to 
the symphysis menti, and for about two inches on each side, is supplied 




Manner of applying the four-tailed 
bandage. 



FKACTURES OF THE LOWER JAW. 



129 



with thread-holes, for the purpose of attaching a piece of linen, which, 
when the apparatus is in place, shall cross in front of the chin, and pre- 
vent the maxillary strap from sliding backward against the front of the 
neck. 



Fig. .34. 



The advantage of this dressing over any which I have yet seen, consists in its 
capability to lift the anterior fragment almost vertically, whilst at the same time 
it is in no clanger of falling forward, and downward upon the forehead. If, as 
in the case of most other dressings, the occipital stay had its attachment oppo- 
site to the chin, its effect would be to draw the central fragment backward. By 
using a firm piece of leather as a maxillary band, and attaching the occipital 
stay above the ears, this difficulty is completely obviated. 

Having removed such teeth as are much loosened at the point of frac- 
ture, and replaced those which are loosened at other points, Unless it be 
far back in the mouth, and adjusted the fragments accurately, the lower 
jaw is to be closed completely upon the upper, and the apparatus snugly 
applied. It is not necessary in most cases to buckle the straps with 
great firmness, since experience has shown that a sufficient degree of 
immobility is usually obtained when the apparatus is only moderately 
tight. 

If the integuments are bruised and tender, a compress made of two or more 
thicknesses of sheet lint should be placed underneath the chin, between it and 
the leather. If the inability to introduce 
nourishment between the teeth when the 
mouth is closed, or the irregularity of the 
dental arcade renders the use of inter- 
dental splints necessary, gutta-percha 
ought, in general, to be preferred to any 
other material. 

The patient must be forbidden to talk 
or laugh, and when he lies down, his 
head should rest upon its back, for what- 
ever mode of dressing is employed, and 
however carefully it is applied, it will be 
found that a slight motion and displace- 
ment will occur whenever the weight of 
the head rests upon the side of the face. 

Occasionally, indeed as often as 
every two or three days, the appa- 
ratus may be loosened or removed, 
only taking care generally not to dis- 
turb the interdental splints, when 
they are used, and to support the jaw 

with the hand, during its removal ; The author's apparatus. 

and, at the same time, the face may 

be sponged off with warm water and castile soap. It should not be left 
off entirely, however, in less than three or four weeks, even where the 
fracture is most simple, nor ought the patient be allowed to eat meat in 
less than four or five weeks. 




To cleanse the mouth and prevent offensive accumulations, it should be washed 
several times a day with a solution of tincture of myrrh, prepared by adding 
one drachm to about four ounces of water. 



130 FRACTURES OF THE LOWER JAW. 

The same apparatus, and without any essential modification, is applic- 
able to fractures of the symphysis and of the angle of the inferior max- 
illa, as well as to fractures of the body of the bone. 

Instead of the leather, I have in a few instances, especially of compound frac- 
tures where it became necessary to allow the pus to discharge externally, used 
a sling or a splint composed of gutta-percha, suspended by bands carried over 
the top of the head. The piece from which this splint is made should be three 
or four lines in thickness, covered with cloth, and padded under the chin. It 
will be found convenient to cover it with cloth before immersing it in the hot 
water. The water should be nearly at a boiling temperature, so that the splint 
may become perfectly pliable ; and it should be laid upon the face and allowed 
to mould itself while the patient lies upon his back. Having thus fitted it 
accurately to the face, it may be removed and openings made at points corre- 
sponding with the wounds upon the skin, before it is reapplied. 

As has been already explained, the gutta-percha, if sufficiently thick, 
and if the lateral wings are allowed to project a little on either side, will 
serve effectually to protect the sides of the face against pressure from 
the bandage ; and being more easily moulded to the base and front of 
the chin than any other material which has yet been employed, must 
have the preference. The necessity for its use, however, is only occa- 
sional. 

Dr. S. O. Vander Poel 1 has employed successfully a modification of my appa- 
ratus, made of plaster-of-Paris bandage. The apparatus having been applied 
over a linen nightcap, and having been permitted to harden, the maxillary 
straps are cut on a line with the ears, or portions removed and pieces of web- 
bing with buckles substituted. The pieces of webbing may be fastened with 
stitches or with plaster. Perhaps it would be quite as well to leave the bandage 
as at first applied until a change becomes necessary — possibly a week or two — 
and then cut and insert the webbing. 

In fractures of either condyle, unaccompanied with displacement, the 
simple leather or muslin sling will sometimes accomplish a perfect and 
speedy cure, as the two cases reported by Desault will sufficiently demon- 
strate. But if the fragments have become separated, the' replacement is 
difficult, and the retention uncertain. 

Eibes was the first to suggest and to practise a very ingenious method of re- 
duction in these cases. Malgaigne thus describes his procedure : "With the 
left hand seize the anterior portion of the jaw, for the purpose of drawing it 
horizontally forward, while you carry the index finger of the right hand to the 
lateral and superior part of the pharynx. You will meet at first the projection 
formed by the styloid process, but, moving your finger forward, you will find 
soon the posterior border of the ramus of the jaw ; and following this border 
from below upward, you will arrive at the inner side of the condyle, which you 
will push outward in such a manner as to engage it upon the other fragment. 
This manoeuvre cannot be made without causing nausea, as the finger always 
does when carried into the posterior part of the pharynx ; but this is a slight 
inconvenience. The reduction obtained, bear the jaw upward and backward in 
order to press and fix the condyle between it and the glenoid cavity, then fasten 
it in place with a sling. In addition to these means, the angle of the jaw ought 
to be pressed permanently forward by means of a compress placed between it 
and the mastoid process, and held in place by a suitable bandage ; or we may 

1 Vander Poel, Archives of Clinical Surgery, Jan. 1, 1878. 



FRACTURES OF THE HYOID BONE. 131 

adopt the method which proved so successful with Fountain, namely, wire the 
front teeth of the lower jaw to the front teeth of the upper in such a manner as 
to draw the chin forward, and thus maintain apposition. 

If the coronoid process be alone broken, it is sufficient to close the 
mouth with any form of sling or bandage which may be most convenient. 

In cases of delayed or non-union of the fragments, we may resort to 
the wire ligature, or to any other of those expedients described. 

In Dr. Muhlenberg's tables, 14 cases are recorded. Of 7 treated by mecchanical 
appliances, 5 were cured, 1 was relieved, and 1 died; and of 7 treated by 
drilling, with its modification, all were reported cured, 



CHAP TEE XIV. 

FRACTURES OF THE HYOID BOXE. 

Poinsot collected eleven cases. An analysis of these, with the eleven 
cases recorded by me, shows that the fracture was caused by hanging, 
five times ; by grasping the throat between the thumb and fingers, six 
times ; by direct blows, eight times ; and by muscular action, three 
times. 1 

The observation of Mr. South, that fracture of this bone "is almost invariably 
found" 2 in persons executed by hanging, is probably incorrect, since although a 
large proportion of these subjects are submitted to dissection in this and other 
countries, yet I know of but these three examples which have been published. 

The body of the bone seems to be broken in all of those cases in which 
fracture resulted from hanging; while in all of the other examples the 
fracture has occurred in one of the great horns, or at the junction of the 
horns with the body. Generally the displacement inward of one of the 
fragments has been so complete that crepitus could not be detected. In 
two instances the mucous membrane had been penetrated, and in one the 
fragment was projected between the epiglottis and rima glottidis. 

The following cases illustrate some of the peculiarities of this fracture : M. 
Orfila has reported the case of a man, aged sixty-two years, who had been 
hanged, and whose os hyoides was broken through its body on its right side. 
M. Cazauvieilh has also seen a fracture of this bone in two persons who had been 
hanged, in one of whom the fracture was probably in the body of the bone, and 
in the other through one of its cornua. 4 Lalesqne relates {Journal Hebdomadaire, 
March, 1833) the case of a marine " who, in a quarrel, had his throat violently 
clinched by the hand of a vigorous adversary. At the moment there was very 
acute pain, and the sensation of a solid body breaking. The pain was aggra- 
vated by every effort to speak, to swallow, or to move the tongue, and when this 
organ was pushed backward, deglutition was impossible. The patient could not 

1 Poinsot, !N"ofe to French edition of this treatise, p. 149. 

2 Xote to Chelius's Surgery, Amer. ed., vol. i. p. 581. 

3 Traite de Med. legale, troisieme ed., torn. ii. p. 423. 

4 Cazauvieilh, du Suicide, etc., p. 221. 



132 FRACTURES OF THE HYOID BONE. 

articulate distinctly; and he was unable to open his mouth without exciting a 
great deal of pain. He placed his hand upon the anterior and superior part of 
his neck to point out the seat of the injury. This part was slightly swollen, and 
presented on each side small ecchymoses ; one above, more decided, immediately 
under the left angle of the lower jaw. The large corn u of the os hyoides was 
very distinctly to the right side," and it could be felt on the left deeply seated 
by pressing with the fingers ; in following it in front toward the body of the 
bone, a very sensible inequality near the point of junction of these two parts 
could be perceived. By putting the finger within the mouth, the same projec- 
tions and cavities inverted could be felt, and even the points of the bone which 
had pierced the mucous membrane, etc., were evident. Having placed a plug 
between his teeth to keep the mouth open, the broken branch was brought by 
the finger back to the surface of the body of the bone, and easily reduced. The 
position of the head, inclined a little back, rest, absolute silence, composed the 
after-treatment. To avoid a new dislocation by the efforts of swallowing, the 
cesophagus-tube of Desault was introduced, to conduct the drinks and liquid 
aliments into the stomach ; this sound was allowed to remain until the twenty- 
fifth day; at this time the patient could swallow without pain, and began to 
take a little more solid nourishment, and at the end of two months the cure was 
complete. By placing a finger within his mouth, a slight nodosity could be felt 
in the place where, in the recent fracture, the splintered points were perceptible. 1 

Dieffenbach recorded a fracture of the great right horn, produced in the same 
manner, by grasping the throat between the thumb and fingers, which occurred 
in a girl only nineteen years old. Very slight pressure upon the side of the 
bone was sufficient to move the fragment inward, and to produce a crepitus; but 
it immediately resumed its place when the pressure was removed. There being 
no displacement, the cure was effected in a short time without resort to any 
remedies. She was not even forbidden to speak. 2 Auberge saw a similar case 
in a person fifty-five years old, occasioned by grasping the throat. The fracture 
was in the great horn of the right side, and the displacement was so complete 
that crepitus could not be felt, and the mucous membrane of the pharynx was 
penetrated by the broken bone. 3 

Dr. Wood, of Cincinnati, examined a fracture of the os hyoides that had 
occurred about one week before. The patient, a female, had fallen down the 
cellar-steps, striking the prominent parts of the larynx and hyoid bone against 
a projecting brick, severely injuring the larynx as well as fracturing the bone. 
The fracture was on the left side, and near the junction of the great horn with 
the body of the bone. Crepitus was distinctly felt on pressing the bone between 
the thumb and finger ; or when the patient would swallow ; though, at this 
time, the severe symptoms that followed the accident, and continued for several 
days, had somewhat subsided. Immediately after the accident there was pro- 
fuse bleeding from the fauces, and she experienced great difficulty and pain in 
the act of swallowing, and the power of speech was almost entirely lost. On 
attempting to depress or protrude the tongue, she felt distressing symptoms of 
suffocation. Considerable inflammation and swelling of the throat and larynx 
ensued. In about four weeks the patient had so far recovered as to be able to 
converse, though the voice was somewhat impaired. She was yet unable to 
swallow solid food, and was wholly sustained by fluids. 4 Marcinkovsky saw 
a woman in whom both the lower jaw and the left horn of the os hyoides 
were broken by a fall from her carriage against a wall. She died in about 
twenty-four hours, from suffocation. 5 Dr. Grunder reports the following: "A 
laborer, set. sixty-three, fell from a wagon on his face, and discharged a large 
quantity of blood by the mouth. He found he could not swallow, and when 
seen twelve hours afterward, complained of severe pain in the neck and nape, 
with inability to turn his head, though no injury of the vertebrae could be de- 
tected. His voice was hoarse and difficult. On attempting to drink, the fluid 

1 Amer. Journ. Med. Sci., vol. xiii. p. 250. 

2 Medic. Vereinszeitung fur Preussen, 1833, No. 3; Gazette Med., 1834, p. 187. 
» Revue Med., July, 1835. 

4 Western Lancet; also N. Y. Journ. Med., vol. xv. p. 152. 

5 Medic. Vereinszeitung fur Preussen, 1833, No. 15,- Gazette Medicale, 1833, p. 354. 



FRACTURES OF THE HYOID BONE. 133 

was rejected with violent coughing, the patient declaring he felt it as if entering 
the air-passages. An examination of the fauces led to no explanation of this 
condition. The epiglottis did not, however, appear to close completely the 
larynx, or to be in its exact position. The tongue was movable in all direc- 
tions, and pressing it down with a spatula caused no inconvenience. The hyoid 
seemed to possess its continuity. No crepitation or abnormal mobility could be 
perceived, and no pain at the root of the tongue occurred on attempting to 
swallow. After repeated examinations, the case was concluded to be one in 
Avhich the functions of the nervus vagus had undergone great disturbance, or 
the muscles of the larynx had become torn or paralyzed. Medicine and food 
were administered by means of an elastic tube. The patient had a good appetite 
and slept well ; the pain of the neck was lost, and its motion recovered ; a hectic 
cough, from which he had long suffered, alone remaining. After continuing, 
however, to go on thus well for six days, the cough increased ; the appetite 
failed ; strength was lost; the voice w T as scarcely audible ; and in five more days 
the patient died exhausted. At the autopsy a fracture of the os hyoides was 
found. One of the large cornua was broken, and had become firmly imbedded 
between the epiglottis and rima glottidis, inducing the raised position of the 
epiglottis, loss of voice, and difficulty in swallowing." 1 A woman, fifty-six 
years old, made a misstep and fell backward, and at the same moment that her 
head was thrown violently back, she felt distinctly a sensation as if a solid body 
had broken, in the upper part of her neck and upon its left side. An examina- 
tion showed that she had fractured the great left horn of the 6s hyoides. 
Inflammation and suppuration followed, and finally, after about three months, 
the posterior fragment made its way out in a condition of necrosis, and the 
fistula promptly healed, but there remained for many years a sense of uneasiness 
about these parts when she swallowed, sometimes amounting to pain. 2 

James G. La Roe, of Greenpoint, X. Y., has reported the case of a man set. 
twenty-seven, in whom the right cornu was broken at its junction with the 
body in the act of gaping. During fifteen or twenty days he was unable to 
swallow either liquids or solids, except in very small quantities. Complete rest 
was enjoined, and he was permitted to hold his head in that position which he 
found most comfortable, inclining to the right and forward. He made a complete 
recovery. 3 

Symptoms. — The accident has been characterized by a sudden sensa- 
tion as if a bone had broken ; in a few instances, by profuse bleeding 
from the fauces ; by difficulty in opening the mouth ; by impossibility of 
deglutition, and by loss of voice in others ; with great pain in moving 
the tongue, the pain being especially at its root ; in one instance the 
tongue w 7 as perceptibly drawn to one side. There is usually more or less 
swelling and soreness about the neck, with ecchymosis ; and at a later 
period, cough, expectoration, hoarseness, etc. The circumstances which, 
however, indicate certainly the nature of the accident, are preternatural 
mobility of the fragments, with or without crepitus, and the angular 
inward projection, which may in most cases be distinctly felt in a careful 
examination of the pharynx. In the case related by Griinder, the only 
symptoms were a loss of voice, difficulty of deglutition, and a sensation, 
when the attempt was made to swallow, as if the fluids passed into the 
windpipe ; with also an imperfect closure of the epiglottis upon the rima 
glottidis. No preternatural mobility or irregularity in the fragments 
could be detected, nor was there crepitus, and it was concluded that the 
bone was not broken, yet the autopsy showed that the fragment w T as 
imbedded deeply between the epiglottis and the rima glottidis. 

1 Schmidt's Jahrbuch., vol. lxviii. : also Amer. Journ. Med. Sci., vol. xlix. p. 253, 
Jan. 1852. 

2 Malgaigne, op. cit , p. 405. 3 La Roe, Med. Record, April 15, 1882. 



134 FRACTURES OF THE HYOID BONE. 

Prognosis.— It is only in view of its complications that this accident 
can be regarded as serious ; where the severity of the injury has been 
such as to fracture the lower jaw at the same time, as in the case related 
by Marcinkovsky, or such as to bury the fragment deep in the tissues 
about the rima glottidis, as in the case mentioned by Griinder, a favor- 
able termination could scarcely have been expected. Five of the eleven 
recorded by me have died ; but of these, three have died by hanging, and 
the remaining two from the causes named. Of the three in which the 
accident resulted from a direct blow, only the patient of Dr. Wood, of 
Cincinnati, has survived; while of the three whose fractures resulted 
from lateral pressure upon the cornua, all recovered ; so, also, did the 
two patients in whom the fracture was produced by muscular action. 

[Union by callus has been demonstrated in several cases, as in the example 
given by Gurlt, where the fracture was through the right greater cornu.] 




United fracture of the hyoid bone. 

Treatment. — No doubt when the fragments are displaced an attempt 
ought to be made to replace them by introducing one finger into the 
mouth, while with the opposite hand the fragments are supported from 
without. Lalesque found this a matter of some difficulty, but Auberge 
experienced no difficulty at all. The degree of difficulty will very much 
depend upon the degree of displacement, and the consequent lacerations 
of the soft tissues about the bone. But however this may be, it must be 
altogether another thing to be able to keep in exact apposition the broken 
ends of a bone whose diameter is so inconsiderable, and upon which it is 
quite impossible to apply any apparatus or dressings to retain the frag- 
ments in place. Lalesque threw the head of his patient slightly back, 
with the view of making "permanent extension" upon the fragments 
through the action of the muscles and ligaments attached to the bone, 
and he recommends this position as that which is best calculated to pre- 
serve the coaptation. Malgaigne, on the contrary, without having him- 
self seen any example of this fracture, believes that the position of flexion 
of the neck, with entire relaxation of the muscles, would be most suitable ; 
and this was the position in which La Roe's patient found himself most 
comfortable. 



FRACTURES OF THE CARTILAGES OF THE LARYNX. 135 

[Pick 1 directs the patient to be placed in a " bed-chair," with the head thrown 
slightly back, and fixed in this position by a coronal bandage and two braces 
passing to the shoulder on either side, as is employed in cases of cut-throat. 
The neck should be encircled by a collar made of soft chamois-leather spread 
with adhesive plaster and evenly applied.] 

In all cases it will be proper to enjoin silence, and to adopt suitable 
measures to combat inflammation, such as topical bleeding, fomentations, 
moistening the mouth with cool water, or permitting small pieces of ice 
to rest in the mouth until dissolved, without in general allowing the fluid 
to be swallowed ; but in some examples, no doubt, the patient may be 
permitted to swallow. In case the life of the patient is in danger from 
starvation, the surgeon may be compelled to resort to nutritious enemata, 
or possibly to the use of the stomach-tube. The latter method is liable 
to the serious objection that the tube is apt to cause irritation. When 
asphyxia is threatened, laryngotomy or tracheotomy may be demanded. 



CHAPTER XV. 

FRACTURES OF THE CARTILAGES OF THE LARYNX. 

The following summary of 62 cases of fracture of the laryngeal 
cartilages is compiled from the 52 cases collected by Henocque, and 10 
additional cases collected by Durham : 2 

Cartilages fractured. Cas'e« Deaths. Recoveries. 

Thyroid only .24 18 6 

Cricoid only 11 11 

Thyroid and os hyoides 4 2 2 

Thyroid and cricoid ....... 9 9 

Thyroid, cricoid, and os hyoides 2 2 

Thyroid, cricoid, and trachea ■ 2 2 

Cricoid and trachea ....... 2 2 

Cricoid, trachea, and os hyoides .... 1 1 

" Fractures of larynx " 7 3 4 

62 50 12 

General Etiology of Fractures of the Laryngeal Cartilages. — As a 
predisposing cause, advanced age, with its usual concomitant, partial or 
complete ossification of trie cartilages, has been thought to occupy a 
prominent place. 

In the case reported by Plenck, the cartilages were already very much ossified, 
although the subject was only thirty-seven years old. Morgagni observed that 
in his experience it had occurred always in advanced life. In my own case, 
however, the cartilages were only slightly ossified, the patient being forty-one 
years old ; nor did the lines of the several fractures indicate a preference for the 
bony plates ; but it seems to me that they rather avoided them, and in the case 
of the incomplete fracture the bone appeared to have arrested the fracture. In 

1 Fract. and Disloc. 2 Malgaigne, op. cit., p. 408. 



136 FRACTURES OF THE CARTILAGES OF THE LARYNX. 

fact, a few experiments have satisfied me that the adult laryngeal cartilages are 
quite as brittle as bone, and, consequently, that ossification in no way increases 
their liability to fracture. Hunt ascertained the age in fifteen cases, and but 
one of the whole number was over forty -five years; five occurred in children, 
one of whom was only four years old. 

The immediate causes have been direct blows, as falling upon the edge 
of a pail, a kick from a horse, or pressure, as in hanging, or in grasping 
the larynx strongly between the thumb and fingers, and in gunshot 
injuries. 

General Symptomatology, etc. — The signs of this accident are such 
as may attend any severe injury of this organ, whether accompanied 
with a fracture or not, such as pain, swelling, difficult deglutition, em- 
barrassed respiration, loss of voice, cough, and perhaps bloody expecto- 
ration, with emphysema, etc. But none of those can be regarded as 
diagnostic ; although, when taken in connection with the history of the 
■ accident, especially if a very severe and direct blow has been received, 
or more certainly still when symptoms so grave and complicated have 
followed an attempt at strangulation by grasping the throat, they may 
be regarded as probable or presumptive evidences. A positive diagnosis 
must depend upon the presence of a sensible displacement, or motion of 
the fragments, with crepitus. 

In the case related by Plenck, death followed almost immediately, with con- 
vulsions, and without any outcry ; indicating, probably, some severe lesion of 
the spinal marrow ; whilst in M. Ollivier's patient suffocation ensued, at first 
intermittent, and finally permanent. Gurlt reports 12 examples of sudden 
death following these lesions, of which he thinks at least 3 were unaccompanied 
by lesion of the spinal cord. In my own case, suffocation was throughout a 
prominent symptom, with only such slight intervals of amelioration as might 
have been occasioned by the extrication of the blood or mucus from the larynx. 

General Prognosis. — The prognosis ought to depend rather upon the 
seat, complications, and gravity of the injury, than upon the simple 
decision of the question of fracture. A fracture produced by grasping 
the wings of the thyroid cartilage, and without any great contusion or 
laceration of the soft parts, might reasonably be expected to terminate 
favorably under judicious management ; but when, on the contrary, the 
fracture is the result of great violence inflicted directly upon the front of 
the cartilages, producing severe contusion and laceration, and is followed 
by great swelling, emphysema, very difficult respiration, complete 
aphonia, impossibility of deglutition, etc., the prognosis cannot but be 
unfavorable. 

By reference to the table at the beginning of this chapter it will be seen that 
all of the cases — 27 in number — in which the cricoid was involved, terminated 
fatally. The only cases involving the cricoid in which recovery has taken 
place have been certain examples of gunshot injuries. 

General Treatment. — In examples of simple, uncomplicated fracture, 
" silence, regimen, and a small bleeding " may suffice ; but in other cases 
it may become necessary to introduce a tube into the stomach, to supply 
the patient with food and drink, since deglutition may be impossible. 
If, also, suffocation is imminent, there may remain no alternative but a 
resort to tracheotomy. Indeed this operation ought, we think, to be 



FRACTURES OF THE CARTILAGES OF THE LARYNX. 137 

resorted to in all cases in which emphysema is prominent, or in which 
respiration is interfered with seriously. 

Hunt, of the Pennsylvania Hospital, who has arranged a tabular synopsis of 
twenty-nine cases, says that of seventy-seven cases ten recovered and seventeen 
died. Of eight cases in which tracheotomy was performed, but two died. In 
the four cases in which recovery took place without an operation, no mention is 
made of bloody expectoration or of emphysema. 1 

[Hunt's opinion of the necessity of an operation is not too emphatic. He 
says : "I think that our list shows that active and prompt treatment by laryn- 
gotomy or tracheotomy gives the only hope of success, where the emphysema 
and bloody expectorations show that the mucous membrane has been lacerated 
by the broken fragments."] 

As to a " reduction " of the fragments by manipulation, I believe it 
will be found generally, if not always, impracticable. Whatever dis- 
placement exists must be mostly inward, and we can have no means of 
forcing them again outward. Nor, if once replaced, do I see any reason 
to suppose that they would not become immediately displaced. 

[Pick [Fractures and Dislocations) suggests that if there is any difficulty in 
maintaining the cartilages in position after restoration, an instrument con- 
structed on the principle of Tredelenberg's tampon canula may be devised for 
this purpose. He also advises, if there is any difficulty in deglutition, to feed 
the patient with fluid food, introduced into the stomach by means of a large- 
sized gum-elastic catheter passed down the oesophagus and connected with a 
stomach-pump in preference to using a stomach-pump tube, which has a ten- 
dency to displace the fractured cartilages.] 

Chelius has suggested the propriety, in such cases, of cutting open the cover- 
ings of the larynx freely in the median line, and, after stanching the bleeding, 
proceeding at once to divide the larynx itself in its whole length, and then re- 
placing the broken cartilages. 2 The procedure has an aspect of severity, but I 
can well conceive of circumstances which would justify its adoption; not, how- 
ever, so much for the purpose of replacing the cartilages, as for the purpose of 
arresting a fatal internal hemorrhage, and of giving a free admission of air to 
the lungs. If this operation were to be practised, the wound ought to be left 
open for a sufficient length of time to allow of the subsidence of the inflamma- 
tion, and then permitted to close with such precautions as experience teaches 
are usually necessary after the windpipe has been opened. 

Antiphlogistic measures, combined with fomentations to the neck, so 
far as these latter are found to be agreeable and practicable, are im- 
portant measures and not to be overlooked in the general plan of treat- 
ment. 

My own patient, also, found small pieces of ice, permitted slowly to dissolve 
in the mouth, very grateful; but he preferred very much, as an external appli- 
cation, the warm fomentations to the cold lotions. 

Note. — Additional references; Fractures of the Larynx. Gurlt, der Knochen, vol. ii. 
Helwig, Casper's Viertelj., 1861, p. 342. "Witte, Arcliiv. far klin. Chir. Langenbeck, Bd. 
21, S. 494-7, 503. Fischer, Krico-Brf., 1 Theil Hefcs., S. 113. Neudorfer. Handb. der 
Kniegs, 2 HafTce, 2 Heft, S. 410. Henocque, Gaz. Hebdom., Sept. 25 and Oct. 2, 1868. 
Fredet. Sur. Frac. du Larynx, 1868. Gaz. des H5p., 1868, Nos 90 and 91. Chailloux, 
These de Paris, 1873. Wales, Amer. Journ. Med Sci . Jan. 1861. Hamilton, Ibid., April, 
1867. O'Brian, Ei. Med. and Surg. Journ.. v. 18. Bui. Sac. Anat., Dec. 1866. Keiller, 
Edin. Med. Journ., 1856, pp. 527. 824. Dublin Quart., May, 1860. Lancet, 1869, p. 707. 

1 Hunt. Amer. Journ. Med. Sci., April, 1866. 

2 System of Surgery. Philadelphia ed , vol. i. p. 531, 1S47. 



138 FRACTURES OF THE THYROID CARTILAGE. 

§ 1. Thyroid Cartilage. 

In twenty-four of the fifty-two cases collected by Henocque, the thyroid 
alone was broken ; and in seven of Poinsot's gunshot cases the same fact was 
observed. Poinsot remarks : " In all the cases of fracture of the thyroid alone 
noted by Henocque, the fracture was produced by lateral pressure, the larynx 
having been violently squeezed between the thumb and fingers. In the cases of 
Piedagorel and Martin-Damourette, the same cause existed. Sometimes, how- 
ever, the fracture seems to have been produced by a direct pressure from before 
backward. Such was a case reported by Mr. Langlet, where an insane man 
suffered with this fracture, which had been caused by the pressure of the edge 
of a straight-jacket. Henocque, and after him Chailloux, insists upon the fact 
that fracture ot the thyroid cartilage, whether isolated or not, has never been 
observed to follow hanging. Contrary to what occurs in the case of the hyoid 
bone, fractures of the thyroid cartilage, whether produced by pressure either, 
lateral or from before backward, are of a grave character. Out of 23 cases, 
Henocque counts no less than 18 deaths. As a singular contrast, in gunshot 
fractures the results are less disastrous ; our seven cases only count two deaths, 
and in these two the fatal termination is explained by the extent of the accom- 
panying lesions. In one of the wounded, the ball, after entering near the 
symphysis mentis, had broken the jaw, had passed under the hyoid bone, and 
lodged itself in the thyroid cartilage. In the other, beside the loss of a portion 
of the anterior part of the thyroid cartilage, the autopsy showed a fracture of 
the humerus, of the left clavicle and shoulder-blade, and of the right side of the 
lower jaw. Of the four wounded who recovered, two were operated upon by 
tracheotomy. In the one operated upon by Maas, a Chassepot ball having frac- 
tured the left ala of the thyroid cartilage, considerable emphysema of the neck 
and chest supervened within a few moments, the blood flowing into the trachea. 
Maas performed superior tracheotomy during a severe paroxysm of asphyxia, 
and the patient recovered without any accident. Muller only operated on his 
patient on the second day, when there existed some cyanosis, resulting from 
dyspnoea, and a well-marked infiltration of the neighboring tissues ; the cure 
was accomplished also without any untoward event. 

" Goetting's patient, who had both lamellae of the thyroid cartilage traversed 
through their middle and from right to left by a Chassepot ball, exhibited, as 
soon as wounded, symptoms of suffocation which he thought would prove fatal ; 
but these phenomena subsided entirely before he was placed in the ambulance, 
and he recovered without operative interference. In the case of Fischer's 
patient, no accident occurred ; indeed, there was only an incomplete fracture, 
the projectile having only taken off the most superficial lamellae of the pomum 
Adami. But in our last case the cure was no less exempt from complications, 
although, as in Goetting's patient, the ball had traversed the thyroid cartilage 
and had wounded the vocal cords. The patient breathed freely through the 
wound, and at no time were there any symptoms of suffocation. The edges of 
the wound were approximated by means of a silver suture, and it was healed in 
two months." 1 

The following additional cases illustrate the peculiarities of the fractures of 
the thyroid cartilage. M. Ladoz examined the larynx of a man who had 
been assassinated, and upon whose neck he found a handkerchief bound so 
tightly as to leave, after its removal, a deep furrow ; but the neck showed also 
distinct marks produced by the fingers and thumb. There was a fracture of the 
thyroid cartilage which extended obliquely downward and outward through its 
right wing. The whole of the larynx was very much ossified, although the sub- 
ject was only thirty-seven years old. 2 In 1823, M. Ollivier communicated to the 
Academy of Medicine a case in which, this cartilage being broken, the patient 
died of suffocation. 3 M. Marjolin says : " Two women at the hospital being en- 
gaged in a quarrel, one of them seized her antagonist by the throat, and gripped 

1 Poinsot, French edition of this treatise, p. 152. 

2 Gazette Medicate, 1838, p. 698. 

3 Archives Generales de Medecine, tome ii. p. 307. 



THYROID AND CRICOID CARTILAGES. 139 

her so strongly that she broke the thyroid cartilage from its upper to its lower 
margin. Silence, regimen, a small bleeding, and the cure was accomplished." 1 
Habicott operated successfully, in 1620, by introducing a leaden tube into the 
trachea in a case in which the thyroid was " damaged." 

§ 2 Thyroid and Cricoid Cartilages. 

Plenck saw a fracture of both the thyroid and cricoid cartilages produced by 
falling upon the rim of a pail. 2 Eemer mentions a fracture of the larynx found 
in a person who had been hanged. 3 Dr. O'Brian, of Edinburgh, 4 reports a case 
of fracture of both cartilages, involving the trachea also, in a woman who had 
received a kick under the jaw, and who died on the following day. I am able 
to furnish one example of fracture of both the thyroid and cricoid cartilages. 

J. C, set. forty-one, is supposed to have been kicked by a horse on the 10th of 
November, 1856. When found, he was sitting upright, but unable to articulate 
except in a whisper. His countenance was anxious, his pulse feeble, extremi- 
ties cold, and he was breathing with great difficulty. A small quantity of blood 
was issuing from his fauces. His upper lip was cut, and a few of his teeth dis- 
located; the wound appearing as if inflicted by one of the corks of the horse's 
shoes. There was no other wound ; but over the left wing of the thyroid carti- 
lage there was a slight discoloration, pressure upon which produced intense pain 
and suffocation, and disclosed the fact that the thyroid prominence was de- 
pressed very much and broken. Cold lotions were directed to be applied, and 
as the thirst was excessive, but deglutition impossible, he was permitted to hold 
pieces of ice in his mouth. This plan, with but slight modifications, such as 
the substitution of warm fomentations to the neck for the cold lotions, was con- 
tinued until the following evening, when, at the request of the attending 
physician, Dr. Barber, I was called to see him. The symptoms remained nearly 
the same as at first. He was unable to speak audibly, or perform the act of 
deglutition; his breathing was difficult, and at times threatened suffocation. 
The lateness of the hour, with other circumstances, determined me to defer 
surgical interference until morning. At daybreak of the 12th, I made the oper- 
ation of laryngotomy, and introduced a large double canula into the crico- 
thyroidean space. This operation was rendered difficult by the great amount of 
swelling about the neck, due both to emphysema and serous infiltrations. The 
breathing immediately became easy, and gradually the appearance of asphyxia 
disappeared from his face ; but, after about six or seven hours, he began per- 
ceptibly to fail in strength, and died at 3 o'clock p. m. of the following day, 
apparently from exhaustion rather than from suffocation, having survived the 
accident about seventy-two hours, and the operation about thirty-four hours. 
The autopsy disclosed a comminuted fracture of the thyroid cartilage, with a 
simple fracture of the cricoid. The thyroid was broken almost perpendicularly 
through the centre, the line of fracture being irregular and inclining slightly to 
the left side. The left inferior horn was broken off about three lines from its 
articulation with the cricoid cartilage. The right ala was broken also in a line 
nearly vertical, but irregular, at a point about six lines from its posterior margin. 
The pomum Adami was depressed to the level of the cricoid cartilage, and the 
left ala, being completely detached, was thrown inward and upward several lines. 
Underneath the perichondrium, especially upon the inner side, there was pretty 
extensive bloody infiltration. Ossification of the cartilages had commenced at 
several points, but it had made little progress. The central fracture of the 
thyroid was through cartilage alone. The fracture of the right ala was through 
cartilage until it reached a bony belt comprising the two inferior lines of its 
course. The left lower horn was ossified, and the fracture was through this 
bony structure. The fracture through the cricoid cartilage commenced close 

1 Marjolin, Cours de Patholog. Chir., p. 396. 

2 Malgaigne, op. cit., p. 409. 

3 Morgagni, de Sedibus, etc., Epis. 19, num. 13, 14, et 16; Remer, Annales d'Hygiene, 
tome iv. p. 171 ; from Malgaigne. 

4 O'Brian. Edinburgh Med and Surg. Journ., vol. xviii. 



140 FRACTURES OF THE VERTEBRA. 

upon the margin of a bony plate, but in its whole course it traversed only carti- 
lage. It was on the left side. There was also an incomplete fracture on the 
right ala of the thyroid cartilage, commencing in the line of the principal frac- 
ture and extending obliquely downward about three lines, until it was arrested 
by the bony plate which constituted the lower margin of this wing. A ragged, 
lacerated wound in the back of the larynx, above the cricoid cartilages, com- 
municated directly with the oesophagus. 

§ 3. Cricoid Cartilage. 

Both Valsalva and Cazauvieilh have each met with a single example of this 
fracture, without fracture of the thyroid cartilage ; and Weiss has found the 
cricoid cartilage broken into numerous fragments, and at the same time separated 
from the trachea. In the table at the beginning of this chapter, eleven similar 
cases are recorded. 

[§ 4. Fracture of the Condyle of the Occiput. 

Dr. Morgan, of Leavenworth, Kansas, reports the following case as a frac- 
ture of the condyle of the occipital bone: A coal-miner, set. about thirty -five 
years, colored, was injured by the fall of a mass of slate upon him, after which 
for a long time he was unable to turn his head to the right. He partially re- 
covered, but again received a similar injury about three years after. He was 
never again able to move his head in any direction, nor to work. Hemiplegia 
soon after supervened, when he took to his bed. His head became rigidly fixed 
and turned to the left, instead of right, as after the first injury. There was 
paralysis of motion and sensation of the upper and lower extremities of the right 
side ; the prick of a pin was felt on the left side, and the fingers could be slightly 
flexed after massage. There was little pain, except when clonic spasms occurred. 
When his head moved, the whole body had to be moved. His wife, who always 
moved his head, thought she often detected a crepitus. Death occurred sud- 
denly. The autopsy showed a detached piece of bone which had been part of 
the right occipital condyle. The axis was intact, except the odontoid process, 
which was denuded of cartilage and roughened on one side ; the cheek ligaments 
seemed to have been disorganized ; the right transverse process of the atlas was 
found destroyed by caries, and the articular surface of its lateral mass about half 
absorbed, due to the chronic inflammatory process to which the region had 
evidently been subjected. 1 ] 



CHAP TEE XVI. 

FRACTURES OF THE VERTEBRAE. 

It will be convenient to divide fractures of the vertebrae into fractures 
of the spinous processes, transverse processes, vertebral arches, and bodies. 

§ 1. Fractures of the Spinous Processes. 

Fractures of the spinous apophyses, independent of a fracture of the 
arches, may occur at any point of the vertebral column ; and they may 
be occasioned by a blow received upon either side of the spinal column ; 
or by a force directed from above or from below. 

1 Med. "Record, April 19, 1890. 



FRACTURES OF THE SPINOUS PROCESSES. 



141 




Fracture of the spinous process. 



Symptoms and Pathology. — These accidents may be recognized by 
the pain at the point of fracture, produced especially when the patient 
bends forward, which position renders the skin and muscles tense and 
drives the fragments into the flesh; by the swelling, tenderness, and 
discoloration ; but chiefly by the lateral displacement of the broken 
process, and the mobility. 

Duverney met with a fracture of two of the Fig. 56. 

processes in the same person, and which could 
only be recognized by the mobility, since, as 
the autopsy proved, there was no displace- 
ment. Nor would it be surprising if the 
displacement was absent in a majority of these 
accidents, inasmuch as the attachment of the 
ligaments from above and below with the 
strong and short muscles upon either side, 
must prevent a deviation in any direction 
until these tissues are more or less torn. Sir 
Astley Cooper mentions a case in which, how- 
ever, such lacerations did occur, and the 
lateral deformity was quite conspicuous. A 
boy had been endeavoring to support a heavy 
weight upon his shoulders, when he fell, bent 
double. Immediately he had the appearance 
of one suffering under a distortion of the spine 
of long standing. Three or four of the pro- 
cesses were broken off, and the corresponding 

muscles were detached so as to allow the processes to fall off to the opposite 
side. There was no paralysis, and he was soon discharged with the free use of 
his limbs, but the deformity remained. 1 

If the fragment is thrown directly downward, as it possibly may be, 
especially in the cervical or lumbar region, yet not without a rupture of 
the supraspinous ligaments, or of the ligamentum nuclide, then the dis- 
placement will be more difficult to detect, and it may require some more 
care not to confound it with a fracture of the vertebral arch or of the 
plates from which the spinous processes arise. The process not being 
felt in its natural position, nor upon either side, it may seem to have 
been forced directly forward, when, in fact, it is only thrown downward 
toward its fellow. The danger of error in the diagnosis will be increased 
when to these conditions is added paralysis of those portions of the body 
which are below the seat of the fracture, and which, in this case, may 
be the result of an extravasation of blood or of simply a concussion of 
the spinal marrow. Nor do I think it would be possible now to deter- 
mine positively whether it was simply a fracture of a spinous process, of 
the arch, or of the body itself of the vertebra. In case, however, the 
paralysis results from concussion, the fact will in most cases soon become 
apparent by a return of sensation and of the power of motion. 

Prognosis. — Hippocrates affirmed that here, as in fractures of other 
spongy bones, the union took place speedily. It is quite probable that 
he has stated the fact correctly, and yet in the only example known to 
me where the condition of this process, as proved by dissection, has been 
carefully stated, the fragment had not united by bone at all. 



1 Sir Astley Cooper, op. cit., p. 459. 



142 FRACTURES OF THE VERTEBRAE 

This is the case related by Sir Astley Cooper as having been examined by 
Mr. Key. A subject was brought into the dissecting-room in which one of the 
processes had been broken, and, on dissection, a complete articulation was 
found between the broken surfaces, which surfaces had become covered with a 
thin layer of cartilage. The false articulation was surrounded with synovial 
membrane and capsular ligaments, and contained a fluid like synovia. 1 

Ordinarily the displacement continues, whatever treatment may be 
adopted. 

Malgaigne says he has seen one instance in which the twelfth dorsal spine, 
being broken and displaced laterally, resumed its place spontaneously after a 
few days. Aurran mentions a similar example. 2 

Treatment. — If in any case it should be found possible to act upon 
the fragment, an attempt might be made to press it into place, and to 
retain it there by means of a compress and bandage ; but even this would 
not be admissible so long as any doubt remained whether it was not a 
fracture of the vertebral arch, since, if it were, any attempt to restore 
the bone to place by pressure would be likely to drive it more deeply 
upon the spinal marrow. Yet what need is there of surgical interference 
of any kind ? If the apophysis remains displaced, it cannot result in 
any serious, perhaps we may say in any appreciable deformity. The 
surgeon has therefore only to lay the patient quietly in bed, and in such 
a position as he finds most comfortable, enjoining upon him perfect rest, 
and employing sucli other means as may be proper to combat inflamma- 
tion. 



§ 2. Fracture of the Transverse Process. 

A fracture of a transverse process can scarcely occur except as a con- 
sequence of a gunshot wound. 

Dupuytren relates a case of this kind in which the ball had penetrated the 
transverse process of the second cervical vertebra. 

C. H. was shot with a pistol ; saw him on the following day ; ball had entered 
the chin, a little to the left side and below the inferior maxilla, but its place of 
lodgement could not be discovered ; lay with his face constantly turned to the 
right ; left side of his neck was swollen and crepitant ; the left arm and leg 
were paralyzed ; slept most of the time, but could be easily aroused, and when 
aroused he seemed to be conscious, but was unable to speak ; by signs indicated 
that he was suffering no pain. He gradually sank, without hemorrhage, and 
died in thirty-six hours from the time of the receipt of the injury. 

The autopsy enabled us to trace the wound from the chin through the roots 
of the transverse process of the fourth cervical vertebra ; immediately behind 
which, lying imbedded in the muscles, was the bullet. The cavity of the tunica 
arachnoides contained considerable serous effusion. 

[Dr. Armstrong, of Taylorsville, 111., reports a case of fracture of the right 
transverse process of the atlas, caused by a blow on the back of the neck by 
a baseball-bat or a wagon-spoke. The man, set. thirty-two, lived only one 
minute and fifteen seconds. The autopsy showed a complete separation of the 
right transverse process of the atlas.] 

1 Sir Astley Cooper, op. cit., p. 459. 

2 Malgaigne, op. cit., p. 412. 



FRACTURE OF THE VERTEBRAL ARCH 



143 



Symptoms. — The symptoms arising from this accident can only refer 
to the complications, since a mere fracture of the process is not likely 
to present any peculiar signs which could be recognized. Concussion or 
bloody effusion may take place so as to occasion more or less paralysis : 
or, at a later period, inflammation and its consequent effusions may give 
rise to the same phenomenon. In itself considered, and independent of 
these complications, it is sufficiently trivial ; but inasmuch as it has not 
been known to occur except from gunshot wounds, nor is it likely to 
occur except from penetrating wounds of some kind, the accident must 
always be regarded as exceedingly grave, if not actually fatal. 

Treatment. — As to the treatment, nothing but strict rest and anti- 
phlogistic remedies can prove of any service. 

§ 3. Fracture of the Vertebral Arch. 

The vertebral arches, upon which both the spinous and transverse 
processes have their principal support, may be broken at any point of 
their circumference, by a blow received upon the spinous process ; but 
generally it is the lamellar portion, or the "vertebral plate," which gives 
way rather than the neck or pedicle of the arch ; and in nearly all of 
the cases recorded the plates have been broken upon both sides. The 
only exception to this rule, of which the author is informed, is the speci- 
men said to be in the museum of Yal-de-Grace, and mentioned by M. 
Lequest. 1 » 

A balustrade fell from the top of a high building, striking a man about forty 
years of age upon the back of his head and neck. He fell to the ground 
instantly and did not again move his feet or 
legs, although he never lost his consciousness 
until he died. The bladder was paralyzed, 
and his left arm, but he could move his right 
arm. He conversed freely up to the last mo- 
ment, and said that he was suffering a good 
deal of pain, which was always greatly aggra- 
vated by moving. His death took place thirty- 
six hours after the receipt of the injury. Dis- 
section disclosed the fact that the plates of 
the sixth cervical vertebra were broken upon 
each side, and that the spinous process, with a 
small portion of the arch attached, was forced 
in upon the spinal marrow. There was no 
blood effused or serum at this point, but about 
one ounce of serum was found in the cavity of 
the tunica arachnoides at the base of the 
brain. The bodies of the vertebrae were not 
broken. The immediate cause of death was 
the direct pressure of the spinous process. 

[Walker, of Detroit, reports a case of frac- 
ture of the fifth cervical vertebra in which the arch separated on both sides at 
its junction with the body. It was caused by a fall upon the head. 2 ] 

Symptoms. — We can imagine a case of fracture of the vertebral arch, 
with a lateral displacement only, in which the symptoms might not differ 



Fig. 5" 




Fracture of the vertebral arch. 



1 M. Lequest, Die. Encyc, 3d Series, vol. i. p. 446. 

2 Med. Age, Detroit, 1886. 



144 FRACTURES OF THE VERTEBRA. 

essentially from a simple fracture of the spinous process ; and it is quite 
possible that some of the cases which have been supposed to be examples 
of this latter accident, and in which a speedy recovery has taken place, 
were really examples of fractures of the arches ; yet it must be admitted 
that such a fortunate result is only possible, since the arches can hardly 
be broken without communicating a severe concussion to the marrow, 
nor without lacerations, inflammation, and effusions, which will be most 
certain to produce compression and paralysis, and probably death. 

If, however, it is possible for us to confound a fracture of the process with a 
fracture of the arches, it is still more possible to confound a fracture of the 
arches with a fracture of the body of the vertebrae. If, as is usually the fact, 
the process, in case of a fracture of the arch, is less prominent than natural, 
and that portion of the body receiving its nervous supply from below this point 
is paralyzed, we may have reasons to believe that the arch is broken and the 
process is driven in upon the spine; but dissections have shown that in many 
of these cases, or in most of them, indeed, the bodies of one or more of the 
vertebrae are broken also, and in still other cases the bodies alone were broken. 
If we can feel the plates move separately, the diagnosis might be made out, so 
far at least as to determine that the plates were broken ; but we would be still 
unable to say that the bodies of the vertebrae were not broken also. Something, 
perhaps, may be inferred from the direction and manner of the blow which has 
produced the fracture. Thus, a fall upon the top of the head, the feet, or the 
nates, would most often produce a comminution of the bodies by crushing them 
together, whilst a blow upon the back could scarcely break one of the vertebrae 
without breaking the corresponding arch also. We might thus be led to infer, 
in the first instance, that the arches were not broken ; and, in the second instance, 
if we could convince ourselves that the arches were not broken, we might rest 
pretty well assured that the bodies were not. 

Treatment. — If the fragments are not displaced, nothing but rest and 
a cooling regimen are indicated ; but if they are forced in upon the 
marrow, an important question is presented, and which has received 
from different surgeons different solutions. Shall an effort be made to 
reduce the fragments ? and, if so, by what means shall the indication be 
attempted ? It will be remembered that in nearly all of these cases we 
must remain in doubt, even after the most careful examination, as to the 
actual condition of the fracture. It may be that what we suppose to be 
a fracture of the arch is only a fracture of the apophysis, or that, on the 
other hand, it is a fracture of the body of the bone itself; and if we are 
expert enough to make out clearly a, fracture of the arch, it is not 
possible for us to say that the body is not broken also, indeed, it is quite 
probable that it is broken. With a diagnosis so uncertain, can we ever 
find a justification for surgical interference ? Death is inevitable, sooner 
or later, if the fragment is not lifted, and we can scarcely make the 
matter any worse by interference. If it proves to be a fracture of the 
apophysis our interference was unnecessary, but it has done no harm. 
If the body of the bone is broken, the operation affords no resources, but 
the patient is probably beyond suffering damage at our hands. If the 
diagnosis is correctly made out and the arch only is broken, and if there 
is no bloody effusion, or laceration of the membranes or of the marrow, 
and if the concussion was not sufficient to determine much inflammation 
of the cord, then it would seem possible that an operation might save the 
patient. 



FRACTURE OF THE VERTEBRAL ARCH. 145 

Paulus iEgineta first suggested that the compressing fragments ought to be 
removed by excision ; and in 1762 Louis removed from a man who had received 
a gunshot wound in his back, after the lapse of five days, several loose pieces of 
bone belonging to the arch of the vertebra, and the patient recovered, but not 
without a partial paralysis of his lower extremities. Of course, nothing could 
be more rational or simple than this procedure, adopted by Louis, in any case of 
an open wound, where the fragments could be easily reached ; but the younger 
Cline was the first, in the year 1814, to put into practice the more ancient sug- 
gestion of Paulus iEgineta, namely, to attempt the removal of the fragments in 
a case of simple fracture. He made an incision upon the depressed bones as 
the patient was lying upon his face, raised the muscles covering the spinal arch, 
removing, by means of a circular saw, chisel, mallet, trephine, etc., the spinous 
processes of the eleventh and twelfth dorsal vertebrae, and the arch of one of 
the vertebrae. The patient was in no manner relieved, and died on the fourth 
day after the receipt of the injury and the third after the operation. 1 Mr. Old- 
know repeated this operation in 1819 in a case of fracture of the arch of the 
seventh vertebra. The patient died on the sixth day. 2 In 1822, Mr. Tyrrell 
operated on a man who had been injured four days previously, removing the 
spinous processes of the twelfth dorsal and first lumbar vertebrae. The operation 
was accomplished with considerable difficulty, and resulted in only a partial 
return of sensibility. He died on the thirteenth day after the operation. 3 In 
1827, Tyrrell operated a second time, and death resulted on the eighth day. 4 On 
the 30th of August, 1824, Dr. J. Rhea Barton, of Philadelphia, operated upon 
a man who had received, twelve days before, a fracture of the arch of the 
seventh dorsal vertebra. On the third day he was attacked with a violent chill, 
and death took place twelve hours after. The dissection showed about half a 
gallon of blood in the posterior mediastinum, and bloody effusion existed along 
the whole length of the spinal canal. 5 The patient whom Laugier trephined at 
the base of the spinous process of the ninth dorsal vertebra, died on the fourth 
day. 6 The operation has been repeated unsuccessfully by Wickham, Atten- 
burrow, Holcher, Heine, and Roux. 7 February 5, 1834, Dr. David L. Rogers, 
of New York, operated upon a man who had fallen two days before, breaking 
the arch of the first lumbar vertebra, and forcing the spinous process upon the 
cord. This man died on the eighth day. 8 In 1854 Dr. Blackman, of Cincin- 
nati, operated, his patient dying on the fourth day. During the same year, 
also, Dr. B. removed a portion of the sacrum for an injury of four years' stand- 
ing, with no benefit. 9 In 1858 Dr. Stephen Smith, of New York, removed the 
arch of the tenth dorsal vertebra, death occurring soon after. 10 December 29, 
1857, ten days after the receipt of the injury, Dr. J. C. Hutchison, of Brooklyn, 
operated upon a man, removing the spinous processes of the eighth, ninth, and 
tenth dorsal vertebrae, with the posterior arch of the latter. The patient sur- 
vived the operation ten days. 11 Dr. H. A. Potter, of Geneva, N. Y. , informs us 
that he has operated three times. In the first case he removed the posterior 
portion of the three lower cervical vertebrae. The patient died on the fourth 
day. In the second case he removed the spinous processes of the fifth and sixth 
cervical vertebrae, and the entire posterior arch of the fifth. The sheath was 
not broken, "but the cord was much injured." There was almost complete 
paralysis of the extremities, and this condition was not remedied by the opera- 
tion. Three years later, the patient being still alive, but only a very slight 
improvement having taken place, Dr. Potter " removed the fourth, sixth, and 

1 Cline, Chelius's Surgery, Amer. ed., vol. i. p. 590. 

2 Oldknow, Sir A. Cooper on Disloc. and Frac, Amer. ed. 1851, p. 479. 

3 Sir A. Cooper's Lectures, by Tyrrell, 3d Amer. ed., 1831, vol. ii. p. 17. 
* Tyrrell, Med.-Chir. Rev., vol. x. p. 601. 

5 Barton, Goodman's ed. of Sir A. Cooper on Disloc, etc., p. 421. 

6 Malgaigne, Amer. ed., p. 341. 

7 Chelius's Surgery, Amer. ed., vol. i. p. 590. Also, Velpeau's Op. Surgery, 1st Amer. 
ed., vol. ii. p. 737. 

8 Rogers, Amer. Journ. Med. Sci., May, 1835. 

9 Velpeau's Surgery, Blackman's ed., vol. ii. p. 392. 

10 Stephen Smith, New York Journ. Med., 1859, p. 87. 

11 Hutchison, Trans. N. Y. Med. Soc, 1861, p. 93. 

10 



146 FRACTURES OF THE VERTEBRJ. 

seventh cervical vertebrae." (We presume he intends to say the "posterior 
arches.") At the time of the report, January, 1863, there was no further improve- 
ment. Finally he reports a completely successful case. The injury was of 
" five months' standing." 1 Lucke operated on the eleventh dorsal vertebra, and 
the patient died three months later. In 1867 M. Denuce, of Bordeaux, operated, 
the day following the accident, upon a man aged twenty- four years, who had a 
fracture of the last dorsal arch. The arches of the last dorsal and first lumbar 
were elevated. The spinal marrow did not appear to be contused, although he 
had complete paralysis of the lower extremities. The man died two days later. 2 
These are all of the cases of which the author has any information in which 
this operation had been made, and they have all, excepting the case reported by 
Potter (which is doubtful), terminated fatally in a very short time. 

Experience seems to have shown that we have little or nothing to 
expect from operative measures ; and, notwithstanding the strong hope 
expressed by Sir Astley Cooper that Mr. Cline's operation might here- 
after prove a valuable resource, and contrary to the conclusions which I 
in common with many other surgeons had drawn from the anatomical 
relations of these parts, I am compelled reluctantly to declare that the 
expedient is scarcely worthy of a trial. 

To the same conclusion, also, many of the most distinguished surgeons have 
arrived, among whom we may mention, as especially entitled to confidence, 
Brodie, Liston, Alexander Shaw, Malgaigne, and Gibson. " Chedevergne, after 
analyzing the previous papers of MacDonnel and of Felizet, has collected 25 
cases of trephining of the spine, which give the following results : 12 operations 
performed in the dorso-lumbar region show 10 deaths, 1 cure, and 1 unknown 
result; out of 13 operations performed in the cervical region there were 9 
deaths and 4 recoveries ; making a total of 25 operations, with 19 deaths and 5 
recoveries. This ratio of successful cases, as Chedevergne says, might possibly 
be smaller than that furnished when the cases are left to themselves. 3 

What more can be said of the attempt to raise the depressed bone by 
seizing the spinous process with the fingers, or with a pair of strong 
hooked forceps passed through the skin, or finally, if this cannot be done, 
by laying bare both sides of the process and seizing upon it with a pair 
of firm tenacula ? 

This is the alternative presented to Malgaigne, and which he ventures to 
recommend as deserving a trial. In the absence, however, of any testimony in 
its favor, beyond the mere rational argument adduced by this distinguished 
writer, we must waive any further consideration of the subject; only expressing 
our conviction that it will be found, after a fair trial, as useless and as inexpedient 
as the more severe operations of Cline. 

[Macewen operated upon a fracture of the spine five weeks after the accident 
and removed the arches of the twelfth dorsal and first lumbar vertebrae, with 
most satisfactory results. Horsley removed the eleventh and twelfth dorsal with 
benefit to his patient. Gordon operated on the twelfth dorsal and first lumbar 
vertebrae sixty-seven days after the accident and relieved the cystitis, inconti- 
nence, and partially the paralysis of motion. Dandridge, of Cincinnati, re- 
moved the arches of the eleventh and twelfth dorsal and first lumbar six months 
after the injury, but the results were negative. 

Unsatisfactory as operations have thus far proved to be, there are exceptional 
cases in which operations will prove useful. Macewen has thus expressed the 
opinion that is entertained by the most advanced surgeons on this subject : 

1 Amer. Med. Times, Jan. 10, 1863. 

2 Lucke, Denuce, French ed. of this treatise, p. 167. Ppinsot. 

3 Chedevergne, Poinsot, op. cit., p. 167. 



FRACTURES OF TIIE BODIES OF THE VERTEBRA. 147 

" Traumatic lesions are, as a rule, so gross, and the destruction so complete, that 
in such operative treatment can be of little service. Still there are cases in which 
traumatism has produced localized pressure, primary or secondary, which can be 
relieved."] 

Jeffries Wyman, of Boston, has met with eleven specimens of old united frac- 
tures of the vertebral arches occurring in the fourth or fifth lumbar vertebrae 
between the lower articulating and the transverse processes. He has also met 
with the same fracture once in the third lumbar vertebra. The frequency of 
this peculiar form of fracture in this region, Dr. Wyman ascribes to the fact that 
the upper and lower articulating processes are widely separated from each other, 
and connected only by a narrow neck, in which respect they contrast very 
strongly with the dorsal vertebras; and he supposes that the fractures maybe 
caused by either a forcible bending of the body backward, or by the shock 
resulting from a fall from a height in which the force of the concussion is con- 
veyed downward through the pelvis. In no case has the existence of this frac- 
ture been recognized during life, nor is it probable that its occurrence would 
cause any marked symptoms unless it had been caused by a blow directly from 
behind. 1 

As to the therapeutical treatment of the various symptoms belonging 
to these accidents, and in relation to the prognosis, the remarks which 
we shall make will be found equally applicable to fractures of the bodies 
of the vertebrae, and we shall reserve the consideration of these topics 
for the following section. 



§ 4. Fractures of the Bodies of the Vertebrae. 



The same causes which produce fractures of the arches may produce 
fractures of the bodies of the vertebrae — that is, blows received 
directly upon the extremities of the spinous processes; but in these cases 



Fig. 58. 



Fig. 59. 





'TTf 



Fractures of the bodies "with compression. 

the arches are generally broken at the same time. In other cases the 
bodies of the vertebrae are broken by falls upon the top of the head, by 
which the vertebrae are not only driven forcibly together (Figs. 58, 59), 



1 Wyman, Boston Med. and Surg. Journ., Aug. 12, 1860. 



148 



FRACTURES OF THE VERTEBRA 



but often doubled forward upon each other; or the patient may have 
alighted upon his feet or upon his sacrum. 

Malgaigne says the spine bends at three principal points ; comprised, the first 
between the third and seventh cervical vertebrae, the second between the eleventh 
dorsal and second lumbar, the third between the fourth lumbar and the sacrum ; 
and that a majority of the fractures of the vertebras occur at these points of 
flexion. He makes an argument from this also that these fractures " are gen- 
erally the result of counterstrokes, as the effect of forcible flexion of the column 
either forward or backward." Malgaigne observes, moreover, that dislocations 
follow the same rule. M. Chedevergne thinks that indirect fractures are much 
more frequent than direct, and he makes of these two varieties, namely, those 
caused by tearing and those caused by crushing, the former being the result of 
forced flexion forward or backward, the lesion being usually at the twelfth dorsal 
or first lumbar. By experiment on the cadaver, M. Chedevergne has determined 
that in flexion. forward the apophysis of the twelfth dorsal vertebra is broken 
off, the great superspinous ligament torn, and finally the body of the vertebra is 
separated into two parts, of which the superior is the smallest. In flexion 
backward the primary lesion takes place in front. 1 

The direction of the line of fracture varies greatly in the different 
examples which we have seen ; some are crushed or more or less com- 
minuted. In some cases a narrow piece is fractured from the margin, 
others are broken transversely (Fig. 60), and others obliquely. In oblique 



Fig. 60. 



Fig. 61. 





Transverse fracture of the body of a vertebra. Oblique fracture of the body of a vertebra. 

fractures the line of the fracture is generally from behind forward, and 
from above downward. The upper fragment is almost always that which 
suffers displacement ; sometimes being simply driven downward, and thus 
made to penetrate more or less the lower fragment ; at other times, as in 
certain transverse fractures, it is only displaced forward, and in still other 
examples, where the fracture is oblique, the upper fragment is displaced 
both downward and forward (Fig. 61). In the first and last of these examples 
the spine becomes bent forward at the point of fracture, producing an angle 
of which the most salient point posteriorly is represented by the extremity 
of the spinous process belonging to the broken vertebra; in the second 



1 Chedevergne, Mem. de l'Acad. de Med., Paris, 1869-70, torn. 29, p. 73. 



FRACTURES OF THE BODIES OF THE VERTEBRA. 149 

example the spinous process of the broken vertebra is depressed, and the 
process of the vertebra next below is relatively prominent. In a pretty 
large proportion of cases also the fracture of the body of the vertebra is 
complicated, as we have already stated, with a fracture of the arches, in 
some instances with a fracture of the oblique processes, and with a dis- 
location. (Fig. 62.) 

Fig. 62. 




Displacement of upper vertebra downward and forward with compression of cord. 

Symptoms — The usual signs of the accident are severe pain at the 
seat of fracture, felt especially when the part is touched or the body is 
moved, tenderness, swelling, ecchymosis, occasionally crepitus, a slight 
angular distortion of the spine, or simply a trifling irregularity in the 
position of the processes, and paralysis of all the parts whose nerves take 
their origin below the fracture. 

The paralysis may be due to the mere pressure of the displaced fragments, 
but it is much more often due to a severe and irreparable lesion of the cord 
itself. I have, in one instance, seen the cord almost completely separated at the 
point of fracture, although the displacement of the fragments was inconsider- 
able. Accompanying the paralysis of the bladder, there has been generally 
observed an alkaline state of the urine, and subacute inflammation of the coats 
of the bladder. Priapism is present in a certain proportion of cases. Those 
who die immediately seem to be asphyxiated ; while those who die later wear 
out from general irritation, this condition being frequently accompanied with an 
obstinate diarrhoea and vomiting. A few become comatose before death. A 
certain proportion finally recover, but scarcely ever are all the functions of the 
limbs and of the body completely restored. 



1 . Fractures of the Bodies of the Lumbar Vertebrce. 

The spinal cord terminates, in the adult, at the lower border of the 
first lumbar vertebra, but in the child at birth it extends as low as the 
third lumbar vertebra. The remainder of the vertebral canal is occupied 
by the leash of terminal nerves called collectively the cauda equina. 
The nerves which emerge from the intervertebral foramina below the 



150 



FRACTURES OF THE VERTEBRAE 



fourth and fifth lumbar vertebrae, unite with the sacral nerves to form a 
plexus which supplies the sphincter and levator ani, the perineal muscles, 
the detrusor and accelerator urinse, the urethra, the glans penis, and a 
great proportion of the lower extremities. It will be apparent, there- 
fore, that a fracture, with displacement, of even the last vertebra of the 
column, involves the possibility of more or less paralysis of all those 
parts supplied by this plexus, and that in proportion as the fracture is 
higher in the vertebral column, will the probability of additional compli- 
cations be increased. In other words, in addition to the more or less 
complete loss of function in the organs supplied by the ilio-sacral plexus, 
there will probably be associated loss of function in other organs, sup- 
plied from sources above this point of the vertebral canal. A fracture, 
however, of the bodies of the fourth or fifth lumbar vertebra, produced 
by a direct blow, is exceedingly rare, owing to the protection which it 
receives from .the alse of the pelvis. 

Dr. Alexander Shaw has reported four cases of fracture below the second 
lumbar vertebra, which were unaccompanied with any degree of paralysis, and 
which were followed by speedy recovery, 1 a circum- 
Fig. 63. stance which he ascribes to the fact that the cauda 

equina is composed of nerves possessing considerable 
firmness, and suspended loosely together; for this 
reason they escape pressure by slipping among them- 
selves, and suffer less injury from the same amount of 
compression than the medulla spinalis. 

In the two following cases the results were less for- 
tunate, yet recoveries seem to have taken place. A 
boy was admitted into St. George's Hospital with a frac- 
ture and considerable displacement of the third and 
fourth lumbar vertebrse, with a manifest alteration in 
the figure of his spine. His lower limbs were para- 
lyzed. An attempt was made to restore the displaced 
vertebrae, but it was attended with only partial success. 
At the end of a month he had slight involuntary 
motions of the lower extremities, and at the same time 
he began to recover the power of using them volun- 
tarily. Three or four months after the receipt of the 
injury he left the hospital, and the history of his case 
was interrupted at this date. 2 Dr. Thompson, of 
Goshen, N. Y. , reports also a fracture of either the 
third or fourth lumbar vertebra, followed by recovery. 
The patient fell from the roof of a house, striking first upon his feet and then 
upon his buttocks. The usual signs of a fracture were present, such as paralysis, 
etc. A bedsore formed above the top of the sacrum, and a piece of bone exfoli- 
ated, which seemed to belong to the last lumbar vertebra. He was confined to 
his bed seven months. After eighteen months he began to use crutches. At the 
end of about three years all improvement ceased, at which time he could not 
quite stand alone ; yet, with the aid of apparatus, he was able to get about the 
country and vend books, prints, etc. This was also his condition one year 
later. 3 _ 

[Chisholm, of New Concord, 0., reports a case of fracture and displacement 
of the third lumbar vertebra. There seems to have been a marked prominence 
of the spinous process, with paralysis of motion. Gradual recovery took place 
without active treatment. 4 ] 




Key's case of fracture of the 
first lumbar vertebra. 



1 Shaw, London Med. Gaz., vol. xvii. 

2 Brodie, Sir Ast. Cooper on Disloc, op. city, p. 471. 

3 Thompson. Amer. Journ. Med. Sci., Oct. 1857. Lente's paper, 
* Med. Brief, St. Louis, March, 1889. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 151 



Fig. 64. 



2. Fractures of the Bodies of the Dorsal Vertebras. 

In these examples the same organs are paralyzed as in the fractures 
lower down, in addition to which there is generally considerable disturb- 
ance of the functions of respiration, irregular action of the heart, indi- 
gestion, accompanied with a tympanitic state of the bowels. 

In Sir Astley Cooper's cases, mention is made of a fracture of the twelfth 
dorsal vertebra, which the patient survived fifty-two days, one of the tenth 
dorsal, which terminated fatally in six days, 
and another of the ninth dorsal, which did 
not result in death until after nine weeks. 
Dr. Parkman presented to the Boston Society 
for Medical Improvement a specimen of frac- 
ture of the fifth dorsal vertebra, the bodies 
of the third and fourth being also displaced 
forward, in which position they had become 
firmly ossified. The spinal cord had been 
completely separated, yet the patient sur- 
vived the accident two months. 1 Dupuytren 
has related also two examples of fractures, 
one of the tenth and the other of the last 
dorsal vertebra, from which the patients com- 
pletely recovered after from two to four 
months' confinement. 2 A similar case is re- 
lated by Lente, of New York : A man having 
fallen a distance of twelve or fifteen feet upon 
his back, was found with nearly complete 
paralysis of his lower extremities and of his 
bladder. Swelling existed over the lower 
dorsal vertebrse, and this point was very 
tender. Subsequently, when the swelling 
subsided, the prominence of the spinous pro- 
cesses of the tenth and eleventh dorsal ver- 
tebras put the question of a fracture beyond 
doubt. Gradually his symptoms improved. 
In six months he was able to walk about the streets, and four years after the 
accident he was employed in a foundry under regular wages, being able to stand 
fifteen or twenty minutes at a time, and to walk half a mile without resting. 
At this time there remained no tenderness in the spine, but the projection of 
the process was the same as at first. 3 

[Erichsen states that when the fracture occurs in the middle or lower dorsal 
regions, so that the lower portion only of the cord is injured, the patient may 
live for many years, even though the cord is completely severed and the spinal 
canal obliterated by the displacement and by the new bone formed in the process 
of repair. He reports the case of a man who fell fifty feet from a tree and 
sustained a fracture of the spine with displacement. He lived nine and a half 
years, and though completely paralyzed below the middle of his body, suffered 
only from cystitis, and finally pyelo-nephritis. The autopsy showed complete 
obliteration of the spinal canal.] 




Fracture through lower dorsal and 
first lumbar vertebrae. 



3. Fractures of the Bodies of the Five Loiver Cervical Vertebra?. 

We shall now have added to the symptoms already enumerated, 
paralysis of the upper extremities, greater embarrassment of the respira- 



1 Parkman, New York Journ. Med., March, 1853, p. 286. 

2 Dupuytren, op. cit., pp. 356-7. 

3 Lente, Amer. Journ. Med. Sci., Oct. 1857, p. 361. 



152 FRACTURES OF THE VERTEBRA. 

tion with diminished action of the heart, and more complete loss of sen- 
sation and volition in the lower part of the body. In general, also, the 
eyes and face look congested, owing to the imperfect arterialization of the 
blood, and death is more speedy and inevitable than in examples of frac- 
ture occurring lower down. 

In ten recorded examples of fractures of the five lower cervical vertebrae, one 
died within twenty-four hours, four in about forty-eight hours, one in eleven 
days, and one lived fifteen weeks and six days, one about four months, one 
fifteen months, and one, reported by Hilton, survived fourteen years. 1 The 
most common period of death seems, therefore, to be about forty-eight hours 
after the receipt of the injury. 

The following cases illustrate the accident: A woman, set. forty-seven, was 
injured by a blow on the back of her neck; was seen by Mr. Greenwood after 
eleven days, at which time she was breathing with difficulty, occasioned by 
paralysis of the intercostal muscles, respiration being carried on by the dia- 
phragm and abdominal muscles alone. This was the extent of the paralysis. 
There seemed to be a depression opposite the fourth and fifth cervical vertebras, 
and pressure at this point occasioned universal paralysis, as did also the acts of 
coughing and sneezing. About three weeks after the accident, she attempted 
for the first time to move in order to have her clothes changed, when she was 
immediately seized with paralysis in the right arm and hand. After this she 
lost her appetite, had frequent attacks of purging, and thus she gradually wore 
out. 2 A patient was admitted into Hotel Dieu, on account of a fracture of the 
fourth cervical vertebra, caused by a fall on the back of his neck, and suffering 
from paralysis of the bladder and extremities. After two months and a half of 
entire rest, he was convalescent, and quitted the hospital, with only slight weak- 
ness in his left leg, and with his head a little bowed forward. In returning 
from a long walk he fell paralyzed, and remained in the open air all night. 
From this time he continued to fail, and died thirty-four days after the second 
fall. On examination after death, the body of the vertebra was found to be 
broken, and also the processes of the fifth, allowing the fourth to slip forward 
and compress the cord. A true callus existed in front of these bones, which 
looked as if recently broken. The cord itself exhibited an annular constriction, 
which Dupuytren conceived to be the seat of the original lesion narrowed by 
cicatrization. 3 

A sailor fell backward from the wharf, striking with the nape of his neck 
upon a bar of iron. I saw him the following day. He was lying upon his back, 
breathing rapidly. His lower extremities were completely paralyzed ; legs and 
feet swollen and purple; right arm completely paralyzed, and his left partially ; 
from a point below the line of the second rib there was no sensation whatever ; 
his bowels had not moved, although he had already taken active cathartics; 
the urine had been drawn with a catheter; the pulse was slower than natural, 
and irregular. He was constantly vomiting. In reply to questions, he said 
that he felt well, articulating distinctly and with a good voice. His eyes 
and face were somewhat congested, but with this exception his countenance did 
not betray the least physical disturbance. He lived in this condition about 
forty hours, only breathing shorter and shorter, and his consciousness remaining 
to the last moment. After death, and before any incision was made, we were 
unable, upon the most minute examination, to detect any irregularity of the 
processes of the cervical vertebrae, or any crepitus; but, on dissecting the neck, 
we found that the arches of the third and fourth vertebrae were broken, and the 
spinous processes slightly depressed upon the cord. The bodies of the corre- 
sponding vertebrae were comminuted, and the vertebrae above were driven down 
upon them, carrying the processes in the same direction. The theca and the 
spinal marrow were almost completely severed upon a level with the fourth 
vertebra. 

A man was thrown backward suddenly from the back end of a wagon, alight- 

1 Hilton, Lond. Lancet, Oct. 27, 1860. 

2 Greenwood, Sir A. Cooper, On Disloc, p. 472. 3 Dupuytren, op. cit., p. 358. 



FRACTURES OF THE BODIES OF THE VERTEBRA. 153 

ing upon the top of his head. I found the symptoms almost an exact counter- 
part of the case just described, except that a crepitus and a mobility of the 
fragments could be distinctly felt in the upper and back part of his neck. His 
death occurred in very much the same manner after about forty-eight hours. 
No autopsy was allowed. We noticed in this case, also, that whenever he was 
turned over upon his face, respiration almost entirely ceased, but it was imme- 
diately restored by laying him again on his back. 

[Dr. Powell, of Collinsville, 111., successfully treated a fracture of the laminas 
of the seventh cervical vertebra by means of a wire frame which arched over 
the head and was supported on the patient's shoulders. By bands passing under 
the chin and behind the occiput and fastened to this arch the head was lifted 
from the cervical vertebra?. 1 ] 

Dupuytren, Sir Astley Cooper, South, and other surgeons have related 
cases simulating fracture, but which proved to be strains of the ligaments 
uniting the cervical vertebrae, accompanied with more or less injury to 
the spinal marrow. In one instance, I have met with what has seemed 
to be a strain of the ligaments and muscles of the neck, but which pre- 
sented no symptoms of serious injury to the spinal marrow. 

4. Treatment of Fractures of the Bodies of the Vertebrae when the 
Fracture occurs in any Portion of the Column below the Second 
Cervical. 

The treatment ought to be, in a great measure, expectant. The 
patient should be laid in such a position as he finds most comfortable, 
and, as far as possible, the spine should be kept at rest, since the most 
trivial disturbance of the fragments, and even that which may cause no 
pain to the patient, is liable to increase the injury to the spine and pre- 
vent the formation of a bony callus. Especially ought the surgeon to 
be careful, while making the examination, not to turn the patient upon 
his face, in which position the spine loses its support and a fatal pressure 
may be produced. The urine should be drawn very soon after the acci- 
dent, and at least twice daily for the next few weeks. Indeed, it is a 
better rule to draw the urine as often as its accumulation becomes a 
source of inconvenience, or whenever the bladder fills, which will in 
some cases be as often as every four or six hours. It is especially 
necessary to attend to those urgent demands of the patient during the 
first few weeks, when the paralysis is most complete generally, and the 
mucous surface of the bladder, already irritated and inflamed by the 
excessively alkaline urine, suffers additional injury from any degree of 
painful distention of its walls. It is unnecessary to say that the frequent 
introduction of the catheter may itself prove a source of irritation, unless 
it is managed carefully and skilfully. This duty ought never to be in- 
trusted to an inexperienced operator. It is not desirable to obtain a 
movement of the bowels during the first few days, by any means, how- 
ever gentle. The effort to defecate, and the consequent motion, will 
probably do much more harm than the evacuation can do good ; and 
especially, for the same reason, ought we to avoid putting into the stomach 
anything which will occasion nausea and vomiting. After the lapse of 
a few days, if reasonable hopes begin to be entertained of a recovery, it 

1 St. Louis Med. and Surg. Journ., 1889. 



154 



FRACTURES OF THE VERTEBRAE. 



will become important to establish regular evacuations of the bowels, 
either by a judicious management of the diet, by gentle laxatives, or by 
enemata. At a still later period, when the inflammatory stage is past, 
and the nerves remain inactive or paralyzed, nothing could be more 
rational than the employment of strychnia in doses varying from the one- 
twelfth to the one- eighth of a grain three times daily. No single remedy 
has more often proved useful in my own practice, or in the practice of 
other surgeons ; but, to derive benefit from this or any other remedy, it 
must be continued for a long time, perhaps for a year or more. Elec- 
tricity is sometimes useful. Passive motion and frictions, good fresh air, 
and nourishing diet, become at last essential to recovery. From an early 
period, and during the whole course of the treatment, great attention 
should be paid to the prevention of bedsores, by supporting all those 
parts of the body upon which the pressure is considerable. For this 
purpose we may employ circular cushions, air-cushions, and air-beds ; 
but water-beds are very much to be preferred to air-beds as a means of 
preventing bedsores. 

Water-beds must be filled with water at a temperature of 68° Fahrenheit, and 
they must be secured in position by side boards, or a kind of shallow box, the 
sides of which are elevated six or seven inches. Permanent extension can be 

Fig. 65. 




Wire-bed. 



employed upon these beds as well as upon ordinary beds. Sometimes a section 
of a bed, three feet square, is found quite as serviceable as an entire bed, inas- 
much as the back and nates are the only parts which are liable to bedsores. 



Fig. 66. 




Bonnet's vertebral gutter. 



The wire-bed is an excellent substitute for the water-bed. It is less expensive, 
more easily managed, more durable, and admits of a much better regulation of 
the temperature. I have seen no bedsores occur where they were in use. In a 



FRACTURES OF THE BODIES OF THE VERTEBRJ2. 155 

few cases it may be found useful to support the back, including the neck and 
nates, with a wire cuirass, well padded; and especially where the confinement 
is greatly prolonged. 

When sores have formed, they should be treated, if sloughing, with 
yeast poultices or the resin ointment. The resin ointment is an ex- 
cellent dressing for the sores after the sloughs have separated. In case 
the surface is only slightly abraded, simple cerate forms the best applica- 
tion. 

In a few instances surgeons have made some slight attempt to reduce the frac- 
ture, or rather to rectify the spinal distortion, generally by the application of 
moderate extension to the limbs, and by laying the patient horizontally upon a 
hard mattress. In no case have the patients derived benefit from the attempt, 
although the deformity was slightly diminished. In no instance did the patient 
appear to have suffered any damage from the attempt. Such manipula- 
tion can seldom serve any useful purpose, and may be a source of mischief; 
although in cases so generally fatal, it might be very difficult to estimate with 
much accuracy the amount of injury done. If by any possibility the fragments 
could be replaced, I know of no means by which they could be kept in place ; 
and in truth we are much more likely to increase the penetration of the spinal 
cord and the general disturbance, than to diminish it, by extension or pressure. 
Moreover, it usually inflicts upon the unfortunate sufferer great pain, and for these 
reasons it ought generally to be discouraged. I have, however, met with two cases 
of fracture of the lumbar vertebrse, in which relief was afforded by permanent 
extension. When the fracture is below the middle of the vertebral column, 
extension, if employed, should be made by adhesive straps, weights and a 
pulley, as in fractures of the femur; the counter-extension being made by the 
weight of the body. It will be understood, however, that when paralysis exists 
the ligation of a limb with bandages will expose the patient to great danger of 
ulceration and sloughing at and below the points of pressure, and the amount 
of extension must be very moderate. The proposition to operate in fractures of 
the bodies of the vertebrse, appears to me too absurd to be entertained for a 
moment. 

[Dr. Bontecou, of Troy, N. Y., recommends extension and counter-extension 
as in fractures of the thigh. In a case of a severe fracture in the cervical 
region he shaved the patient's head and applied adhesive plaster to the sides of 
the face ; a fifteen to twenty pounds weight was attached, and the body was 
placed in an inclined position for over two weeks. He completely 'recovered, 
and an autopsy several years after showed an old fracture of the fourth, fifth, 
sixth, and seventh cervical vertebrae. 

Dr. E. M. Moore 1 has long practised extension and counter-extension in frac- 
tures of the vertebras, applying weights to each leg, and recommends this 
method. 

Mr. Barker, of London, reports a case of fracture and displacement of the 
lower dorsal and first lumbar with paralysis of motion of the left leg and par- 
tially of sensation of the left leg, and hyperesthesia of the right leg. Under 
ether extension was made from the shoulders and ankles with reduction of the 
displaced bone, but displacement returned when extension ceased. Crepitus was 
detected. Permanent extension was then made by attaching a five-pound 
weight to each leg. Subsequently a plaster-of-Paris jacket, and finally a poro- 
plastic jacket were applied, with the result that the patient made an almost com- 
plete recovery. 2 

Although we are not yet in a position to determine with any accuracy the 
value of immovable dressings in fractures and displacements of the vertebras, yet 
they have given results too favorable in such hopeless cases to be set aside. 
Plaster-Of-Paris dressings have been employed in these cases in Bellevue Hospital 
by myself and other surgeons, since 1874, but it has not been an established 

1 Tr. X. Y. Med. Assoc, vol. iii. 1886. 2 Lancet. Aug. 6. 1887. 



156 FRACTUKES OF THE VERTEBRiE, 

method ot practice. Dr. Weist, of Richmond, Ind., in 1879, reduced a fracture 
of the ninth dorsal vertebra during suspension and applied a plaster-of-Paris 
jacket with great relief to symptoms, and recovery was complete on the sixty- 
seventh day. Konig, of Gottingen, in 1880, stated that having used suspension 
and plaster-of-Paris jackets for caries of the vertebrae with great improvement, 
he was led to apply a similar treatment to fresh fractures of the spine ; he did 
not advocate its employment in all cases, but in three cases the result was favor- 
able. Wagner, of Konigshutte, reported two cases with which he was not at all 
satisfied ; in both he was obliged to remove the jacket ; he had seen it produce 
paralysis, and advises its application only after fourteen days. The German 
Congress of Surgeons discussed this dressing in 1881, and it was regarded as 
worthy of trial in selected cases. Dr. Burrell, 1 of Boston, published a paper in 
1887 containing a review of this method, and giving the results of his treatment 
with illustrations. The method consists in suspending the patient with a Sayre's 
apparatus in the same manner as in caries of the spine, and thus overcoming as 
far as possible displacement. Then the ordinary plaster-of-Paris jacket is ap- 
plied and allowed to harden. 

Dr. Burrell's conclusions are as follows: 1. In the immediate correction of 
the deformity and fixation with plaster-of-Paris jacket or other means, we have 
a rational method of treating a large number of cases of fracture of the spine. 
2. Considering the hopelessness of results in fracture of the spine when treated 
expectantly, almost any risk is justifiable. 3. The immediate correction of the 
deformity is imperative if softening of the cord can and does occur from pres- 
sure at the end of forty-eight hours. 4. The suspension of the patient is only 
a means of rectifying the deformity ; certain fractures could be simply pressed 
into position while the patient lies prone or supine. 

The dangers of this treatment are apparent, viz. : A liability, especially in 
fractures in the cervical region, of causing shock, collapse and death, or of 
making greater pressure upon the spinal cord, or, even of severing it.] 

§ 5. Fractures of the Axis and Odontoid Process. 

The phrenic nerve is derived chiefly from the third and fourth cervical 
nerves. If, therefore, the second cervical vertebra is broken, and con- 
siderably depressed upon the spinal cord, respiration ceases immediately, 
and the patient dies at once, or survives only a few minutes. In such 
examples of fracture of this bone as have not been attended with these 
results, the displacement and consequent compression have been incon- 
siderable, or there has been no displacement? at all. 

Mr. Else, of St. Thomas's Hospital, says that a woman in the venereal ward, 
and who was then under a mercurial course, while sitting in bed, eating her 
dinner, was seen to fall suddenly forward; and the patients, hastening to her, 
found that she was dead. Upon examination of her body, it was discovered 
that the processus dentatus of the axis was broken off, and that the head in fall- 
ing forward had driven the process backward upon the cord so as to cause death. 2 
Sir Astley Cooper also relates the case of a man who was shot by a pistol 
through the neck, breaking and driving in upon the spinal marrow both the 
" lamina and the transverse process" of the axis. He died on the fourth day. 3 
Malgaigne has collected three cases of fracture of the odontoid apophysis, all 
of which were accompanied with displacement of the atlas. The first, reported 
by Eichet, died on the seventeenth day ; the second, reported by Palletta, died 
after one month and six days; and the third, by Costes, lived four months and 
two weeks. Swan has reported a case, also, of fracture accompanied with dis- 
location of the head upon the atlas, in which death ensued immediately after. 4 

1 Boston Med. and Surg. Journ., August 25, 1887. 

2 Else, Sir A. Cooper on Disloc, op. cit., p. 462. 

3 Sir A. Cooper on Disloc., etc., op. "cit., p. 476. 

4 Swan, Boston Med. and Surg. Journ., 1877, vol. i. p. 226. 



FRACTURES OF tlXIS AND ODONTOID PROCESS. 157 

Rokitansky says that there is a specimen contained in the Vienna Museum, 
taken from a patient who survived the accident some time, although the frag- 
ments never united. 

M. Denuce, of Bordeaux, has seen a case of incomplete fracture of this process, 
caused by a gunshot, the bail having lodged in the body of the bone. The 
patient survived four weeks. 1 

The following case is reported by Parker, of New York : 

"The patient was a man forty years of age, a milkman by occupation, of 
medium height, of active business habits, and capable of great endurance. His 
life was one of constant excitement, and he was addicted to the free use of 
liquors. He suffered, however, from no other form of disease than occasional 
attacks of rheumatism, for which he was accustomed to take remedies of his 
own prescribing, which were generally mercurials, followed by liberal doses of 
iodide of potassium, 'to work it all out of the system.' 

" On the 12th of August, 1852, while driving a ' fast horse' at the top of his 
speed on the plank road near Bushwick, L. I., he was thrown violently from his 
carriage by the wheel striking against the toll-gate. He alighted upon his head 
and face about fifteen feet from his carriage. Upon rising to his feet he declared 
himself uninjured, but soon after complained of feeling faint; after drinking a 
glass of brandy he felt better, got into his carriage with a friend, and drove 
home to Rivington Street in this city, a distance of more than two miles. There 
was so little apparent danger in this case that no physician was called that 
night. Early on the morning of the following day, Dr. B. was called to visit 
him. He found his patient reclining in his chair, in a restless state, and learned 
that he had suffered considerable pain in the back part of his head and neck 
during the night. He was entirely incapacitated to rotate the head, which led 
to the suspicion of some injury to the articulations of the upper cervical verte- 
brae; but so great a degree of swelling existed about the neck as to prevent 
efficient examination. There was no paralysis of any portion of the body, his 
pulse was about 90, and his general system but little disturbed. The swelling 
so much subsided that on the fifth day an irregularity was discovered to exist 
in the region of the axis and atlas, which had many of the features of a partial 
luxation of these vertebras. 

"At this time he began to walk about the room, having previously remained 
quiet on account of the pain he suffered on moving. He persisted in helping 
himself, and almost constantly supported his head with one hand applied to the 
occiput. He often remarked, if he could be relieved of the pain in his head 
and neck, he should feel w r ell. He began to relish his food, and the swelling 
nearly disappeared at the end of a week, leaving a protuberance just below the 
base of the occiput, to the left of the central line of the spinal column, with a 
corresponding indentation. Notwithstanding strict orders to remain quietly at 
home, on the ninth day after the accident he rode out, and in a day or two after 
returned as actively as ever to his former occupation of distributing milk through- 
out the city to his old customers. During the following four months no mate- 
rial change took place in his symptoms, although he constantly complained of 
pain in his head. For this period he did not omit a single day his round of 
duties as a milkman, which occupied him constantly and actively from five 
o'clock in the morning to early noon. On the 1st of November, Prof. Watts 
examined him, and inclined to the opinion that there was a luxation of the 
upper cervical vertebras. 

" About the 1st of January, 1853, the pains, from which he had been a con- 
stant sufferer, became more severe, and he was heard to complain that he could 
not live in his present condition; he remarked, also, that he had heard a snap- 
ping in his neck. After going his daily round on the 11th of January, he com- 
plained of feeling cold, and afterward of numbness in his limbs. In the evening 
he had a chill, and complained of a pain in his bowels. He passed a restless 
night, and arose on the following morning about six o'clock ; he was obliged to 
have assistance in dressing himself, and experienced a numbness of his left, and 
afterward of his right side. He attempted to walk, but could not without help, 
and it was observed that he dragged his feet. He sat down in a chair and almost 

1 Denuce, Nouv. Die. de Med. et. de Chir. Prat., t. iii. p. S10. 



158 



FRACTURES OF THE VERTEBRJ 




instantly expired, at eight o'clock, A. M., on the 12th of January, precisely five 
months from the receipt of the injury. 

"The autopsy was made thirty hours after death. Muscular development 
uncommonly fine. An unusual prominence discovered in the region of the 
axis and atlas. On making an incision from the occiput along the spines of the 
cervical vertebrae, trie parts were found to be very vascular. These vertebras 
were removed en masse, and a careful examination in- 
stituted. The transverse, the odontoid (ligamenta 
moderatoria), as also all the ligaments of this region, 
excepting the occipito-axoideum, were in a state of 
perfect integrity ; this latter was partially destroyed. 
A considerable amount of coagulated blood was found 
effused between the fractured surfaces, some of it ap- 
parently recent, but much of it was thought to have 
occurred at the time of the accident, and afterward to 
have prevented the union of the bones. The spinal 
cord exhibited no appearances of any lesion. The 
odontoid process was found in the position well rep- 
resented in the accompanying illustration, completely 
fractured off, and its lower extremity inclining back- 
ward toward the cord. Death finally took place, 
doubtless, from the displacement of the process during 
some unfortunate movement of the head, by which 
pressure was made upon the cord. The destruction 
of the occipito-axoid ligament, which would other- 
wise have protected the contents of the spinal cavity, 
must have favored this result." 1 

Vander Poel, of New York, has reported the case 
of a man, set. twenty- one, who had fallen from a car- 
riage upon the back of his head. The symptoms which ensued led his surgeons 
to believe that he had experienced a fracture of the fourth cervical vertebra. 
His condition subsequently improved to such a degree that he was able to per- 
form light labor; but after six months they became aggravated, and he died six 
months and a half after the accident, of apnoea. The autopsy revealed a trans- 
verse fracture of the odontoid process, the transverse ligament being uninjured. 
There was no other fracture of the vertebrae. 2 

Dr. Philip Bevan presented to the Surgical Society of Ireland, in 1862, a 
specimen obtained from the dead-room, and which was supposed to be an 
epiphyseal separation of the odontoid process, occurring in early life. The 
history of the case is not known, although the woman was forty years old when 
she died. It does not appear very clear to us whether this was really an epi- 
physeal separation, or the result of some morbid process. 3 

Dr. W. Bayard, of St. John, N. B., has, however, reported a case of separa- 
tion of the odontoid process in a child, followed by complete recovery. In 
August, 1864, Charlotte Magee, of St. John, set. six years, previously in excellent 
health, fell five feet, striking on her head and neck, causing an immediate im- 
mobility of the head, which continued about two years and a half, when an 
abscess formed in the back of the pharynx, and the bone was spontaneously dis- 
charged. Since then she has been able to move the head freely, and her 
recovery may be said to be complete. 4 The specimen was subsequently pre- 
sented to the New York Pathological Society, and no doubt remains that the 
entire process was thrown off. 

Dr. Stephen Smith, 5 who has written a very instructive paper on this subject, 
has collected 23 cases of separation of the odontoid process, at least 20 of which 
must be regarded as fractures. The ages of the patients range from three years 
to sixty-eight. Eight of this number were spontaneous, the separation being 



Fracture of the odontoid- 
process of the axis. Par- 
ker's case. a. Broken sur- 
face, b. Odontoid process. 



1 Bigelow, New York Journ. Med., March, 1853, p. 164. 

2 Vander Poel, Arch. Clin. Surg., vol. ii. p. 116. 

3 Bevan, Amer. Journ. Med. Sci., April, 1864. From Dublin Med. Press, Feb. 18, 1863. 
* Bavard, Canada Med. Journ., Dec. 1869. 

5 Stephen Smith, Amer. Journ. Med. Sci., Oct, 1871, p. 338. 



FRACTURES OF THE ATLAS. 159 

apparently due to some progressive disease or atrophy of the bone. Two of 
these recovered after the formation of abscesses in the pharynx and the extru- 
sion of the bone. In four cases the fractures were gunshot, and one died. The 
remainder, so far as ascertained, were in consequence of blows upon the head; 
and of these only the girl Charlotte Magee recovered. Of the whole number, 
23, three were without history, two of them being dissecting-room cases. 

Symptoms. — These will depend much upon the cause and complica- 
tions of the accident. In all cases there will be more or less inability 
to support the head in the erect posture, and if displacement exists, or 
if the products of inflammation press upon the cord, a proportionate im- 
pairment of its functions must ensue. 

Treatment. — The treatment consists in absolute quietude, with mode- 
rate extension, effected by means of suitable apparatus. 

[The mode of death in fracture of the odontoid varies. It may be instan- 
taneous from pressure of the broken process upon the medulla ; or the pressure 
may be gradual, in which case the displacement takes place by degrees, giving 
rise to partial paralysis, generally in one hand first, then in the foot of the cor- 
responding side, and finally complete paraplegia of all the parts below the middle 
of the neck, and death follows from exhaustion. The symptoms of a well- 
marked case are very significant. The patient is careful about maintaining the 
poise of the head, and fears to be jostled; he carries his head as if steadying a 
weight upon it unsupported by his hands. The foramen magnum being a little 
posterior to the centre of the skull, patients generally elevate the chin in order 
to preserve the centre of gravity ; whenever they wish to elevate the eyes above 
the ordinary level they support the occiput in the hand, and in looking down- 
ward they support the chin in the hand. If the relations of the head are dis- 
turbed by a shock they seize it upon the sides with both hands, and hold it 
firmly. On attempting to rise from bed they elevate the head with the hand 
applied to the occiput, and in bed turn the head cautiously with the hand. 

A patient manifesting these symptoms after an injury to the head, demands 
the most careful treatment. The cervical vertebrae must be immediately im- 
mobilized by apparatus which retains the head in a fixed position, as nearly 
normal as possible. The dressing may be a sole-leather splint applied to the 
neck and occiput, moulded while wet, or a plaster-of-Paris or silicate dressing 
may be used. With these forms of dressing a patient may soon move about 
cautiously. If the case requires the recumbent position the parts may be firmly 
supported by sand-bags or other firm appliance.] 

§ 6. Fractures of the Atlas. 

I have been able to find only one example of a fracture of the atlas 
alone, and this is the case related by Sir Astley Cooper as having come 
under the observation of Mr. Cline. 

A boy, about three years old, injured his neck in a severe fall ; in consequence 
of which he was obliged to walk carefully upright, as persons do when carrying 
a weight on the head ; and when he wished to examine any object beneath him, 
he supported his chin upon his hand, and gradually lowered his head, to enable 
him to direct his eyes downward. In the same manner, also, he supported his 
head from behind in looking upward. Whenever he was suddenly shaken or 
jarred, the shock caused great pain, and he was obliged to support his chin with 
his hands, or to rest his elbows upon a table, and thus support his head. The 
boy lived in this condition about one year, and after death Mr. Cline made a 
dissection, and ascertained that the atlas was broken in such a manner that the 



160 FRACTURES OF THE VERTEBRAE. 

odontoid process of the axis had lost its support, and was constantly liable to 
fall back upon the spinal marrow. 1 



§ 7. Fractures of the First Two Cervical Vertebrae (Atlas and Axis) 

at the Same Time. 

A woman, set. sixty-eight, fell down a flight of steps, striking upon her fore- 
head, and died immediately. Upon making a dissection, it was found that the 
atlas was broken upon both sides near the transverse processes, and the odontoid 
process of the axis was broken at its base. These fractures were accompanied 
with a rupture of the atloido-odontoid ligaments, and a dislocation of the atlas 
backward. 2 

South says there is a specimen in the museum of St. Thomas's Hospital, 
showing this double fracture. The man had received his injury only a few hours 
before admission to the hospital, and died on the fifth day. On examination, 
the atlas was found to be broken in two places, and the odontoid process of the 
axis at its root. The fifth vertebra was also broken through its body. With 
neither fracture was there sufficient displacement to produce pressure, but a 
small quantity of extravasated blood lay in the substance of the spinal marrow, 
and its tissue was at one point broken down and disorganized. 3 

Mr. Phillips relates that a man fell from a hay-rick, striking upon the occiput ; 
after which, although momentarily stunned, he walked half a mile to the parish 
surgeon, and in two days more he returned to his occupation. About four weeks 
after the accident he was seen by Mr. Phillips, who discovered a small tumor 
over the second cervical vertebra, pressure upon which caused a slight pain. 
He complained also that his neck was stiff, and that he was unable to rotate it. 
No other disturbance of the functions of the body could be discovered. After 
a time the tonsils became swollen, and the patient experienced some difficulty 
in deglutition, and, upon examining the throat, a slight projection or fulness 
was discovered at the back of the larynx, opposite the second cervical vertebra. 
Subsequently he became affected with general anasarca and pleuritic effusions, 
of which he finally died. Up to the last week of his life he was able to walk 
about his bedroom, and his condition presented no other evidence than has been 
mentioned, that he was suffering from an injury of the spine. He died forty- 
seven weeks after the receipt of the injury. 

The autopsy disclosed a fracture with displacement of the atlas, and a frac- 
ture of the odontoid process of the axis. The twq vertebrae were united to each 
other firmly by complete bony callus. 4 

Wynperse describes a specimen of gunshot fractures of both bones, in which 
the ball was found imbedded in callus which united the two halves of the. an- 
terior arch of the atlas. M. Gaucher has also reported a similar gunshot frac- 
ture, the subject of which survived nine months, death finally ensuing upon a 
secondary displacement of the fragments. 5 

1 Cline, Sir Astley Cooper, op. cit., p. 459 

2 Malgaigne, op. cit., torn. ii. p. 333. 

3 Chelius's Surgery, note by South, vol. i. p. 588. 

4 Phillips, Med.-Chir. Trans., vol. xx. 1837, p. 384. 

5 Wynperse, Gauchet. French ed. of this treatise, by Poinsot, p. 189. 



FRACTURES AND DIASTASES OF THE STERNUM. 161 



CHAP TEE XVII. 

FRACTURES AND DIASTASES OF THE STERNUM. 

Fractures and diastases of the sternum are of rare occurrence, 
owing, probably, to the elasticity of the ribs and their cartilages, upon 
which it mainly rests, and also, in part, to the softness of its structure. 
In advanced life, the ossification and fusion of all of its several portions 
becoming more complete, and the 
cartilages of 
coming more 
true fracture 
frequent. 

» Tanrety it rule 

except in eld age 



the ribs also be- 
or less ossified, a 
is relatively more 




soon after puberty 



Sternum, showing the periods at which its sev- 
eral parts unite by bone. (From Gray.) 



[Gurlt gives the proportion of 
fractures of the sternum to those of 
other bones as 1 in 100, and Lons- 
dale as 2 in 1900. Lane 1 states that 
the proportion of fractures of the 
sternum to those of other bones 
found among the bodies examined in 
the dissecting-room has been far in 
excess of these estimates.] 

In some cases no doubt these acci- 
dents ought to be regarded as true 
luxations, inasmuch as occasionally 
the union of the manubrium with 
the gladiolus is by a perfectly formed 
diarthrodial articulation, as was first 
demonstrated by Maisonneuve in 
1842. We have, however, in general 

no absolute means of knowing whether before the accident the several portions 
which compose the sternum were united by bone, by a single piece of cartilage, 
or by two distinct cartilages with a synovial surface interposed. 

Causes. — These fractures are the result of direct blows inflicted upon 
the part, such as the passage of a loaded vehicle across the chest, the 
fall of a tree or of some heavy timber upon the body ; the fracture im- 
plying always that great force has been applied. Indirect blows and 
voluntary muscular action alone have been known also occasionally to 
produce these accidents. 

David (Memoire sur les Contrecoups) mentions the case of a mason, who, in 
falling from a great height, struck upon his back against a cross-bar which inter- 
cepted his fall, in consequence of which the abdominal and sterno-cleido-mas- 
toidean muscles were so stretched that the sternum broke asunder between its 
upper and middle portions. 2 Sabatier reports another case of separation at the 
same point, produced in a similar -manner; 3 and Roland has described a third 
example in a woman sixty-three years old, who, falling from a height backward 



1 Trans. Path. Soc. LoncL, vol. xxxvi. 

2 Boyer on Diseases of the Bones, first Amer. ed., 1805, p. 57. 

3 Malgaigne, from Sabatier, Mem. sar la Fraet. du Sternum. 

11 



162 FRACTUKES AND DIASTASES OF THE STERNUM. 

and striking upon her back, broke the sternum near its centre. 1 Gross and 
Hodgen have recorded similar cases. 2 Ouveilhier saw a man who, having fallen 
from a height of twenty feet upon his nates, was found to have a fracture of the 
sternum. 3 Cussan saw the same result in a person who fell from a third story, 
striking first upon his feet and then pitching over upon his back. 4 Maunoury 
and Thore have reported an analogous case, where a man fell from a height of 
twelve or fifteen metres, first striking upon his feet and then falling over upon 
his back and head. 5 Johnson reports a case in which a laborer had fallen from 
the top of a hay-cart, striking only upon his head. He walked with his head 
much bent forward, and was incapable of either flexing, extending, or rotating 
it any further. The fracture was transverse, and about three inches below 
the top of the sternum, opposite the centre of the third rib, the lower fragment 
projecting in front of the upper. The fragments were easily replaced by simply 
throwing the head back, and fell into place with an audible snap, but imme- 
diately resumed their unnatural position when the head was flexed. They 
finally united, but with a slight projection and overlapping. 6 

Malgaigne expresses a doubt whether all these can be considered as the results 
of muscular action, since, in a certain number of the examples cited, the head 
seems to have been thrown forward by the concussion, and in others, also, there 
is no evidence that the muscles attached to the sternum were put upon the 
stretch. The only remaining explanation is that in such cases the sternum has 
been broken by the violent shock, or contrecoup. In 1877, J. McL., set. twenty- 
seven, was admitted to my service, Bellevue Hospital, who had fallen from a 
height upon his back, causing a separation of the manubrium from the gladiolus. 
There was no sign of contusion over the point of separation, but crepitus was 
distinct. The fragments were easily replaced and maintained in position, so 
that when he left the hospital the line of separation could scarcely be felt. Dr. 
Hodgen reported the case of a man driving under a low bridge, with his head 
very much bent down. The bridge caught his back, opposite the shoulder, and 
crushed him forward, "separating the vertebras in the dorsal region, and break- 
ing the sternum about three inches below its upper end." This man re- 
covered. 

Among the most authentic examples of separation of this bone from muscular 
action alone are those in which it occurred during labor. Chaussier saw two 
cases occurring in young women in their first labors; the separation having 
occurred when the head was thrown backward as far as possible. Compte and 
Martin, 7 Luchette, and Posta 8 have reported similar examples. 

Malgaigne collected three of these cases, and Dr. Packard reports two. The 
separation took place at or near the junction of the first and second pieces of 
the sternum. Dr. Borland has added one more example, which took place at a 
point near the fourth costal cartilage. 9 Malgaigne relates the case of a mounte- 
bank, who, leaning back to lift with his feet and hands a weight, felt suddenly a 
severe pain in the sternal region, and fell over with a fracture of this bone. 

Mr. Ancelot has reported a case from gymnastic exercise. 10 

The mere act of violent coughing has caused diastasis or fracture of the 
sternum. Mr. Howbridge remarks that the ribs and sternum have been broken 
in this way ; but he adds, that in all probability they are weakened by partial 
absorption or atrophy. 11 Lutz reports a case also, of a man set. thirty-eight, the 
subject of rheumatism and asthma, and who had also emphysma of a portion of 
one lung. During a violent fit of coughing he felt something give way on his 
chest. Severe pain followed, and some swelling. Lutz found the manubrium 

1 Ibid., from Bull, de Therap., torn. vi. p. 288. 

2 Gross, System of Surg., 5th ed., vol. i. p. 964. Med. Record (N. Y.), Dec. 22, 1877. 

3 Malgaigne, from Bull, de la Soc. Anat., Juin, 1826. 
i Ibid., from Archiv de Med., Janv. 1827. 

5 Ibid., from Gaz. Med., 1842, p. 361. 

6 London Med.-Chir. Rev., vol. xvii., new series, p. 536, 1832. 

7 Classical Diet. Med. and Surgery, xiv. 70, Venice. Quoted by Borland, loc. cit. 

8 Bolletino delle Scienze Med. di Bologna, 1857. Quoted by Borland, loc. cit. 

9 J. N. Borland, M.D., Boston Med. and Surg. Journ. April 20, 1875. 

10 Ancelot, from Lutz. 

11 Holmes's System of Surgery, 2d. ed., vol. ii. p. 37. 



FRACTURES AND DIASTASES OF THE STERNUM. 163 

separated from the gladiolus, the former being slightly displaced forward. He 
was much relieved of his distress by " stretching his neck and throwing his head 
backward." Lutz directed him to make a deep inspiration, at the same time 
throwing back the head and shoulders. A compress was placed over the projec- 
tion, and secured in place by a broad and firm band covering the entire chest. 
Union took place, but with a slight overlapping. 1 

[Mr. Lane has demonstrated by experiments of the subject that blows on a 
padded shoulder may produce fracture of the sternum.] 

Malgaigne affirms that he has collected in all ten cases which should be re- 
garded as luxations. According to the plan which I have adopted of disregard- 
ing the distinction between fractures, diastases, and dislocations of the sternum, 
for the reason chiefly that the exact diagnosis is in general impossible, and never 
of any practical value, these cases should be included in this enumeration of 
fractures and diastases. 

The following case, which came under my own observation, proves the possi- 
bility of backward displacement of the xiphoid cartilage : 

A man, twenty-eight years old, fell forward, striking the lower end of his 
sternum upon the top of a candlestick, breaking in the xiphoid cartilage. 
During two years following the accident he had frequent attacks of vomiting, 
which were excessively violent and distressing, the paroxysms occurring every 
five or six days. Twelve years after the accident I found the xiphoid cartilage 
bent at right angles with the sternum, pointing directly toward the spine. He 
now suffered no inconvenience from it, except that it hurt him occasionally when 
he coughed. 2 Polaillon relates the case of a woman, set. thirty-five, who, being 
pregnant and wearing a very tight corset, bent herself forward so as to press the 
steel of the corset upon the xiphoid cartilage. The cartilage was thrown back 
and remained in this position, causing for a long time much distress when the 
stomach was disturbed. The surgeons were unable to reduce the fracture, but 
eventually it ceased to cause inconvenience. 3 In Martin's case the accident was 
followed by persistent vomiting ; which was finally relieved when the surgeon 
seized the cartilage with his fingers and restored it to place. In Billard's case 
the cartilage was restored to its place with a blunt hook, after having made an 
incision which penetrated the peritoneal cavity. 

[Horrocks* reported a case of fracture through the ensiform cartilage leaving 
a fragment one inch and a quarter in length, the lower end of which projected 
forward.] 

The direction of these fractures and diastases is generally transverse, 
or nearly so ; occasionally a slight obliquity is found in the direction of 
the thickness of the bone. In three or four examples upon record, the 
direction of the separation was longitudinal. It is not so unfrequent, 
however, to find the bone comminuted. Compound fractures are exceed- 
ingly rare. When the line of separation is transverse, the lower frag- 
ment is generally displaced forward, and sometimes it slightly overlaps 
the upper fragment ; in other cases the direction of the displacement is 
the reverse. 

The following was a remarkable case of separation of the manubrium from 
the gladiolus, accompanied with a true fracture and other complications : 

L. W., set. sixty, fell through the hatchway of a vessel. He had a compound 
comminuted fracture of the right leg, a fracture of the first four ribs on each 
side at their necks, a dislocation of the sternum from the cartilages of both 
second ribs, a dislocation of the left third cartilage from its rib, a dislocation of 
the first from the second bone of the sternum, and a transverse fracture of the 

1 Paper read before the St. Louis Medical Soeiety by F. J. Lutz, A.M., M.D. St. Louis 
Med. and Surg. Journ., July, 1877. 

2 Buffalo Med. Journ., vol. xii. p. 282, Cases of Fractures of the Sternum. 

3 Polaillon, Soc. de Chir. du Paris, p. 97, 1876. (Poinsot.) 

4 Brit, Med. Journ., Dec. 11, 1886. 



164 FRACTURES AND DIASTASES OF THE STERNUM. 

sternum three ; quarters of an inch below the top of the gladiolus. The disloca- 
tion of the manubrium was complete, and it was thrust behind the upper end of 
the gladiolus, underlapping it half an inch. The transverse fracture three- 
quarters of an inch lower down was also complete, and the fragment thus separ- 
ated was divided into two, namely, an anterior and a posterior fragment, by a trans- 



Fio. 69. 



1 j^r ftfe 





Fig. 71. 




Longitudinal fracture. 



Transverse fracture. 



Fracture of the first piece 
of the sternum. 



verse splitting ; the anterior moiety retaining its attachment to the periosteum 
below, and not being displaced, while the posterior moiety retained its attach- 
ment to the periosteum both above and below, and was pushed downward by the 
descent of the manubrium. His mind was clear, but he had paralysis of the 
bladder, and was breathing with some embarrassment. I had no difficulty in 
diagnosticating the dislocation of the third cartilage, and of the manubrium. 
There was no swelling or discoloration on the front of the chest, but it was quite 
tender. His head was not thrown forward. He complained of some soreness 
on the back of his head. His general condition was such that I did not attempt 
reduction. The following day he expectorated blood, and on the third day he 
died. The autopsy revealed some effusions of blood underneath the pleura, but 
no lesions of the heart or lungs. The evidence is in this case conclusive that 
he struck upon his back and head, in fact, that it was a fracture from counter- 
stroke, by which the head, neck, and three or four upper vertebrae were bent 
forward with great force, thus doubling forward the top of the sternum. Dr. 
Kobert Watts, Jr., has reported a very similar case, in which death occurred on 
the same day. The fragments of the sternum were not displaced, but the ribs 
had suffered similar lesions. 1 

Diagnosis. — In a few cases the patients have felt the bone break at 
the moment of the accident. When displacement exists, it may gener- 
ally be easily recognized, and the lower fragment will often be seen to 
move forward and backward at each inspiration and expiration. Crepitus 



1 Watts, Amer. Med. Times, vol. iii. p. 55. 



FRACTURES AND DIASTASES OF THE STERNUM. 165 

may also be detected in some of these examples. To determine its 
existence, the hand should be plaeed over the supposed seat of frac- 
ture, while the patient is directed to make forced inspirations and 
expirations, or the ear may be applied directly to the chest. 

Emphysema has, also, occasionally been noticed, indicating usually 
that the lungs have been penetrated by the broken fragments. The fre- 
quent occurrence of congenital malformations of the sternum should 
warn us to exercise great care in our examinations, lest we mistake these 
natural irregularities for fractures. The point of junction of the first 
and second portions has also occasionally been observed to be somewhat 
projected forward in cases of chronic asthma and emphysema of the 
lungs. 

Bransby Cooper mentions a remarkable instance of malformation of the 
xiphoid cartilage which he at first suspected to be a fracture. It was so much 
curved backward that, as Mr. Cooper thinks, its pressure upon the stomach pro- 
duced a constant disposition to vomit whenever he had taken a full meal, or had 
taken a draught of water. 1 

Prognosis. — In simple fracture or diastasis of this bone, uncomplicated 
w T ith lesions of the subjacent viscera, and especially when the separation 
is the result of muscular action or of counter-stroke, no serious conse- 
quences are to be apprehended. The bone unites promptly by osseous 
or fibrous tissue, even were it is found impossible to bring its edges into 
apposition. Indeed, generally, where the fragments have been once com- 
pletely displaced, although it is not difficult to replace them momentarily, 
a redisplacement soon occurs, and they are found finally to have united 
by overlapping ; but no evil consequences usually result from this mal- 
position. In nearly all of the cases reported in which palpitations, 
difficult breathing, etc., have been charged to the persistence of the dis- 
placement, the injuries were of such a character as to furnish for these 
unfortunate results other and much more adequate explanations. In one 
instance only, already mentioned, serious inconveniences followed from 
a displacement of the cartilage backward. In other cases, however, 
where the fracture is the result of a direct blow, the prognosis is often 
very grave ; a conclusion to which one would naturally arrive from the 
fact already stated, that the fracture of the sternum, thus produced, in 
itself implies the application of great force. An abscess occurring in 
the anterior mediastinum, and caries or necrosis of the bone, are among 
the most common results of a blow delivered directly upon the sternum ; 
complications which generally end sooner or later in death. Blood may 
be also extensively effused into the anterior mediastinum. 

[Bennett, 2 of Dublin, reports a fatal case of fracture of the sternum, very 
oblique in its direction, accompanied by a rupture of the trachea, which had 
separated an inch.] 

Where emphysema is present, we may anticipate inflammation of the 
pleura and of the lungs. 

1 B. Cooper, Princ. and Pract. of Surg., p. 359. 

2 Dub. Journ. Med. Sei., vol. lxxxvi. 



166 FRACTURES AND DIASTASES OF THE STERNUM. 

In several instances, where death has occurred speedily after the injury, the 
heart has been found penetrated and torn by the fragments. Sanson and Dupuy- 
tren have each reported one example of this kind. Duverney has mentioned 
two, and Samuel Cooper says there is a specimen in the museum of University 
College exhibiting a laceration of the right ventricle of the heart by a portion 
of fractured sternum. Watson mentions a case in which the pericardium was 
torn, but the heart was only contused. 1 

Treatment. — When the fragments are not displaced, the only indica- 
tions of treatment are to immobilize the chest, and to allay the inflam- 
mation, pain, etc., consequent upon the injury to the viscera of the chest. 
The first of these indications is accomplished, at least in some degree, by 
inclosing the body, from the armpits down to the margin of the floating 
ribs, with a broad cotton or flannel band. A single band, neatly and 
snugly secured, and made fast with pins, is preferable to, because it is 
more easily applied than, the roller which surgeons have generally em- 
ployed ; it is also much less liable to become disarranged. It should be 
pinned while the patient is making a full expiration. To prevent its 
sliding down, two strips of bandage should be attached to its upper mar- 
gin, and crossed over the shoulders in the form of suspenders. Gener- 
ally the patients prefer the half-sitting posture, with the head and 
shoulders thrown a little backward ; and this is the position which will 
be most likely to maintain the fragments in place, and also to secure 
immobility to the external thoracic muscles, while it leaves the diaphragm 
and the abdominal muscles free to act. The second indication may 
demand the use of the lancet ; but more often it will be found necessary 
to allay the pain and disposition to cough by the use of opium. If, 
however, the fragments are displaced, it is proper first to attempt their 
reduction ; which, as I have already intimated, is generally more easy 
of accomplishment than is the maintenance of them in place until a cure 
is effected. The fragments may sometimes be made to resume their 
natural position by a single full inspiration, but then they usually fall 
back during expiration ; or they may be reduced by straightening the 
spine forcibly, and at the same time drawing the shoulders back. 

[Porter, 2 of Boston, failed in his attempt at reduction by bending the patient 
backward ; on returning to bed the patient took a deep respiration and coughed, 
when the bones snapped forward into place. 

Irwin, 8 U. S. A., placed a large, hard pad, covered with soft material, between 
the scapula; while the patient inspired deeply and the head and shoulders were 
extended well backward, the displaced fragments were returned and retained in 
their normal position by a suitable splint applied over the pad and across the 
spine, the expanded condition of the thorax being maintained by a figure-of-8 
bandage to the shoulder.] 

Verduc and Petit proposed, in those cases in which it was found impossible to 
reduce the fragments by these simple means, to cut down and lift the depressed 
bone. Nelaton suggests the use of a blunt crotchet introduced through a narrow 
incision ; and Malgaigne has thought of another plan, which is, to penetrate the 
skin with a punch, and directing it to the broken margin, to push the fragment 
into its place, but which he does not himself regard as a suggestion of much 
value, since the bone is too soft to afford the necessary resistance ; and, moreover, 
this, in common with all of the other similar methods, is liable, in some degree, 

1 Watson, New York Journ. of Med., vol. Hi. p. 351. 

2 Bost. Med. and Surg. Journ., April 12, 1888. 

3 Med. News, June 23, 1888. 



FRACTURES OF THE RIBS. 167 

to the objection that it may increase the tendency to caries and suppuration, 
already imminent. If reduced, the fragments will probably immediately again 
become displaced ; and, more than all, it still remains to be proved conclusively 
that the mere riding of the fragments is in itself ever a cause of subsequent 
suffering, or even of inconvenience. 

When an abscess has formed in the anterior mediastinum, surgeons have 
occasionally recommended the use of the trephine. Gibson has twice operated 
in this manner at the Philadelphia Hospital, but in each case the caries con- 
tinued to extend, and the patient died ; an experience which has inclined him 
latterly to discountenance the operation. 1 There are other considerations men- 
tioned by Lonsdale, which ought to decide us never to use the trephine in these 
cases: — "For the symptoms denoting the presence of the abscess, when com- 
pletely confined to the under surface of the bone, will be very uncertain ; and 
when the matter collects in large quantities, it will show itself at the margin of 
the sternum, between the ribs, when it can be let out by making a puncture 
with the point of a lancet, without the necessity of removing a portion of the 
bone." 2 Ashhurst, referring to the same point, remarks : "The fact that the 
mediastinal space can be cut into without injury to the pleura is shown by 
many cases, among others by one which came under my own observation." 3 



CHAPTER XVIII. 

FRACTUKES OF THE RIBS AND THEIR CARTILAGES. 

§ 1. Fractures of the Ribs. 

The force requisite to break the ribs is scarcely less than that requisite 
to break the sternum ; and in childhood and infancy it is sometimes 
almost impossible to break them, so that children and even adults are 
often crushed and killed outright, where, although the pressure has been 
directly upon the thorax, the ribs have resumed their positions, and have 
been found not to be broken. I have met with several examples of this 
kind. 

In my records, not including fractures from gunshot injuries, only thirty-two 
patients are reported as having had broken ribs; but, as in several of the cases, 
two or more ribs were broken at the same time, the total number of fractures is 
about sixty-five. If, however, I had always accepted the diagnosis made by 
other surgeons, the number would have been much greater, since I have been 
repeatedly assured that the ribs were broken when, upon the most careful 
examination, no evidence, beyond the existence of a severe pain and of difficult 
respiration, has been presented to me. 

, In old age the cartilages ossify, and the ribs themselves suffer a gradual 
atrophy, which renders them much more liable to break. 

Etiology. — The most common causes are direct blows, of very great 
force, in consequence of which sometimes the fragments are not only 
broken, but more or less forced inward ; occasionally they are the result 

1 Gibson, Institutes and Practice of Surgery, vol. i. p. 269. 

2 Lonsdale, Practical Treatise on Fractures, London. 1838, p. 242. 

3 Ashhurst. Amer. Journ. Med. Sci., Jan. and Oct. 1862. 



168 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

of counter-strokes, and then the fragments, if they deviate at all from 
their natural position, are salient outward ; a species of fracture which I 
have not met with so often. 

Malgaigne has collected eight examples of fractures of the ribs produced by 
muscular action, by the beating of the heart, etc., all of which occurred upon 
the left side. In six additional cases collected by M. Paulet, the fractures were 
upon the right side. Three of these were caused by coughing, and two by a 
sudden movement of the body. It is believed, however, that in all of these 
cases the ribs had previously become atrophied, and perhaps undergone other 
changes in their structure, rendering them liable to fracture from the action of 
trivial causes. Morselli attributes the frequency of fracture of the ribs in the 
insane to trophic changes in the structure of the ribs, dependent upon lesions 
of the nervous centres. 1 

Pathology, Seat, etc. — The fourth, fifth, sixth, and seventh ribs are 
most liable to be broken ; the upper ribs, and especially the first rib, 
being so well protected in various ways as to diminish greatly their lia- 
bility, while the loose and floating condition of the last two ribs gives 
them an almost complete exemption. 

Malgaigne has noticed, also, contrary to the general opinion of surgeons, that 
the ribs are most often broken in their anterior thirds, whether the cause has 
been a direct or a counter blow. My own observations confirm this statement. 

The direction of the fracture is generally transverse or slightly oblique ; 
sometimes it is quite oblique. It is often compound ; and in a few 
instances I have found it comminuted or multiple. Where the fracture 
is compound, it is rendered so generally by the fragments having pene- 
trated the lungs, and not by a tegumentary wound. Displacement 
cannot occur in the direction of the axis of the bone unless several ribs 
are broken at the same time. The fragments are therefore either not at 
all displaced, or they fall inward toward the cavity of the chest, or out- 
ward, or very slightly downward, in the direction of the intercostal 
spaces Sometimes the rib rotates a little upon its own axis. 

Prognosis. — Death occurs sooner or later in a pretty large minority 
of the cases in which the ribs have been broken ; yet not often as a 
direct consequence of the fracture, but only as a result of the injury 
inflicted upon the viscera of the chest, or of other injuries received at 
the same moment. The violent compression of the heart and lungs has 
frequently produced death, and sometimes, as I have more than once 
seen, almost immediately ; or the patients have succumbed at a later 
period to acute pneumonitis, or pleuritis. 

Lonsdale saw a case in which, the body of a man having been traversed by 
the wheel of a wagon, eight ribs were broken, and, death having followed almost 
immediately, the autopsy disclosed a rent in the left auricle of the heart, pro- . 
duced by one of the broken ribs. 2 Dupuytren reports a similar case and has 
also seen several deaths produced by the emphysema, independent of the frac- 
ture. 3 Amesbury has seen a case of death from rupture of the intercostal artery, 
where there was no injury of the lungs. 4 M. Paulet has studied a series of 
examples of rupture of this artery in connection with fracture of the ribs, ob- 

1 Paulet, Morselli, French ed. of this treatise, by Poinsot. 

2 Lonsdale on Fractures, p. 258. 3 Dupuytren, op. cit., p. 79. 
4 Amesbury on Fractures, vol. ii. p. 612. 



FRACTURES OF THE RIBS. 169 

tained from various sources, and has drawn the following conclusions: First, 
lesion of the intercostal artery in this class of accidents is much more frequent 
than is generally supposed. Second, the lesion is always grave, and often 
mortal. Third, it may occur not only after comminuted fractures, but after 
simple, and even after incomplete fractures, provided the fracture is on the 
lower border of the rib. 1 

In several instances observed by me, patients have suffered from pains 
in the side, occasionally from cough, etc., after the lapse of two or more 
years, and I suspect it is no uncommon thing for these injuries to entail 
some such permanent disability, but which is a consequence rather of the 
injury to the viscera of the chest, than of any condition of the broken 
ribs themselves. In general, simple fractures of the ribs unite in from 
twenty-five to thirty days. 

Malgaigne has seen one case of non-union ; Huguier met with another upon 
the cadaver, in' which a complete false joint existed, furnished with a capsule 
and lined with synovial membrane ; 2 Eve, of Nashville, Tenn., saw a case of 
non-union, occasioned, probably, by a caries or necrosis of the bone, since it 
was accompanied with a discharge of matter, and in which a removal of the 
ends of the fragments resulted promptly in a cure of the sinus ; 3 and Samuel 
Cooper says there is a specimen in the Museum of University College, of a 
fracture of six ribs where the fragments are only connected by a fibrous or liga- 
mentous tissue. 4 

The union generally occurs with only a slight degree of displacement. 
After the union is completed, even where there is no displacement, a 
certain amount of ensheathing callus may generally 
be felt at the point of fracture. In some specimens Ftg - 72 - 

sharp spicula, in others broader sheets of bone extend 
along the course of the intercostal muscles from one 
rib to the other, forming a species of ankylosis between 
their adjacent margins. 

Symptomatology. — Acute pain, referred especially 
to the point of fracture, sometimes producing great 
embarrassment in the respiration, and crepitus, are the 
most common indications of a fracture. The pain 
and embarrassed respiration are, however, far from 
being diagnostic, since they are often present in an 
equal degree when the walls of the chest have only j n f rae t U re of rib. 
been severely contused. The crepitus, also, is often 
difficult to detect, owing to the thickness of the muscular coverings, or 
to the amount of fat upon the body, or to the fracture having occurred 
perhaps directly underneath the mammae in the female. The crepitus 
may be discovered sometimes by pressing gently upon the seat of frac- 
ture, or by applying the ear or stethoscope over this point while the 
patient attempts a full inspiration, or coughs ; or we may press upon the 
front of the chest with one hand, while the fingers of the other hand 
rest upon the fracture. 

Occasionally the patient has felt the bone break, and very often he 
feels or hears the crepitus after it is broken, and will himself indicate 

1 Paulet, Poinsot, op. cit., p. 200. 2 Malgaigne, op. cit., p. 435. 

3 Eve, IS. Y. Journ. Med., vol. xv. p. 136. i S. Cooper's Surg., vol. ii. p. 321. 




170 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

very clearly the point of fracture. At the same time that we detect 
crepitus we are able also to discover motion in the fragments, but I have 
once or twice discovered preternatural mobility without crepitus. Em- 
physema, which is almost certainly indicative of a fracture, is present in 
a pretty large proportion of cases. 



Fig. 




Fractured ribs joined to each other by osseous matter. (From Dr. Gross's cabinet.) 



It has been observed by me in 13 out of 32 cases ; generally it did not extend 
over more than two or three square feet of surface ; but in two cases it finally 
extended over nearly the whole bodV. It is remarkable, however, that in only 
four of these thirteen cases did the patients expectorate blood, and then in a 
very small quantity, and usually not until the second or third day. 

Treatment. — In simple fractures, where there is no displacement, or 
where the displacement is only moderate, the chest * should be inclosed 
with a broad belt or band, provided always that it is not found to increase 
instead of diminishing the patient's sufferings. Some patients cannot 
tolerate this confinement at all ; whilst, with a majority, although it is 
at first uncomfortable and oppressive, after an hour or two it affords great 
relief from the distressing pain, and they will not consent to have it 
removed even for a moment. In nearly all cases 
FlG - 74 - of comminuted fracture it is inadmissible, on 

account of its tendency to force the pieces in- 
ward. 

[A simple and efficient dressing is the application 
of a single broad strip of rubber adhesive plaster 
four or five inches broad of sufficient length to pass 
around the body and lap over three or four inches. 
Or the plaster may be applied in strips passing half 
around the body, and overlapping each other.] 

The forearm ought also to be brought across 
the chest at a right angle with the arm, and se- 
cured in this position with a moderately tight 
bandage or sling, so as to prevent any motion in the pectoral muscles. 
As to position, the patient generally prefers to sit up, or he chooses a 
position only partly reclining upon his back ; but there is no positive 
rule to be observed in this matter, except that such a position shall be 
chosen as shall prove most comfortable to the patient. If the fragments 
are salient outward, the fracture having been produced by a counter- 




strips of adhesive plaster 
applied. 



FRACTURES OF THE RIBS. 171 

stroke, they may be reduced by pressing gently upon them from without. 
If, on the contrary, the fragments are salient inward, they will be found, 
in a great majority of cases, to have resumed their positions spontaneously 
or through the natural actions of respiration ; but if they have not, it 
will be exceedingly difficult to restore them. Possibly it may be accom- 
plished by pressing forcibly upon the front of the chest, or upon the 
anterior extremity of the broken rib : yet if the fragments are com- 
minuted, and the ends are much driven in, this method will avail little or 
nothing. 

In such cases several surgeons have recommended that we should cut down to 
the bone and elevate the fragments, but Rossi alone claims to have actually put 
the suggestion into practice. No doubt, if the necessity were urgent, this 
method might be successfully adopted ; or, instead of cutting down to the broken 
rib, we might even seize the fragment with a hook, as suggested by Malgaigne, 
or what in some cases might be even more convenient, with a pair of forceps 
constructed with long teeth, obliquely set upon a firm shaft. Yet the exigency 
which will demand a resort to any of these measures will be exceedingly rare. 
In gunshot fractures, which are nearly all compound and comminuted, the 
loosened or detached fragments should be at once removed. In no case do I 
attach any value or importance to the advice given by Petit, that we shall place 
a compress upon the front of the chest, underneath the bandage, in order to 
reduce the fragments, or to retain them in place after reduction. 

The emphysema generally demands no special attention, since it is 
usually too limited to occasion inconvenience ; and when more extensive, 
it generally disappears spontaneously after a few days, or a few weeks at 
most. 

The advice given by some surgeons, that we ought in these cases to cut down 
to the pleural cavity so as to allow the air to escape freely through the incision, 
seems thus far to have rested its reputation upon a more than doubtful theory 
rather than upon any testimony of experience. Abernethy alone, so far as I 
know, has actually made the experiment, and his patient died. Dupuytren, in 
two cases, made incisions with the lancet at various points of the body, more or 
less remote from the seat of fracture ; a practice, however, in which he con- 
fesses he has no confidence whatever. These patients both died. Dr. Stedman, 
of Boston, has reported the case of a man who, in addition to a fracture of one 
of his ribs, had also a dislocation of the outer end of the clavicle. The emphy- 
sema commenced immediately, and reached its acme on the twenty-second day. 
At this time it had extended over his whole body ; his eyes were closed, and he 
breathed with great difficulty ; but on the forty-fifth day the emphysema had 
entirely disappeared, and he was dismissed cured. The treatment consisted 
chiefly in the free internal use of stimulants, and in the application of band- 
ages ; but the bandages soon became disarranged, and after a few days they were 
entirely laid aside. 1 In one of my own patients, where the emphysema was 
almost equally extensive, the patient recovered after a few weeks, under the use 
of a simple diet, and without any special medication whatever. 

§ 2. Fractures of the Cartilages of the Ribs. 

The cartilages of the ribs are often broken when there is no ossifica- 
tion, at the same time that the ribs themselves are broken. Sometimes 
they are broken alone. Not unfrequently, also, the separation takes 
place at the precise point of junction between the cartilage and the bone. 

1 Stedman, Boston Med. and Surg. Journ., vol. lii. p. 316. 



1^2 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

Puel infers, from experiments upon the cadaver, that the fracture would take 
place at this point most often. 1 Pyper relates a case in which the sternum was 
broken in a man aged twenty-five years, and also the cartilages of the sixth, 
seventh, and eighth ribs of the right side, as was proved by the autopsy, yet the 
cartilages were not ossified. The vena cava ascendens was also ruptured by the 
force of the compression. 2 

Etiology. — The causes are the same as those which produce fractures 
of the ribs, yet it is generally understood that it will require greater 
force, and that consequently the injury done to the viscera of the thorax 
will be more complicated and intense. 

[Several cases of this fracture have been reported as occurring from muscular 
action. A violent effort with the arms at the moment of a fall, or in attempting 
to throw a heavy body, may cause such a strain upon the attachments of the 
pectoral muscles as to cause a lesion of the cartilages.] 

A man was crushed by the fall of a heavy weight upon his body, and died 
after about sixty hours. An autopsy revealed a fracture of the cartilages of the 
third and fourth ribs, with a laceration of the intercostal muscles to such an 
extent that a hernia of the lungs had occurred at this point. 

[Legros Clark 3 reports the case of a man who was struck in the upper part of 
the chest by the pointed shaft of a vehicle ; a tumor the size of the fist appeared 
at each inspiration and disappeared on expiration, leaving a deep depression. 
Examination showed that the cartilage of the second rib had been displaced 
and driven in. Extensive emphysema followed, but he recovered in six 
weeks.] 

Pathology. — The fracture is clean and vertical, or transverse ; never 
irregular or oblique. The direction of the displacement varies as in 
fractures of the ribs, but the anterior or sternal fragment is generally 
found in front of the posterior or spinal. Union takes place in these 
fractures, according to the testimony of most pathologists, not through 
the medium of cartilage, but of bone. Sometimes the new bone is 
deposited only between the ends of the fragments in the form of a thin 
plate ; at other times it is formed around the fragments as well as between 
them. The latter of these two processes has been most frequently 

Fig. 75. Fig. 76. 





Repair of fracture of costal cartilage. 

observed. The ensheathing callus appears to be supplied by the peri- 
chondrium, whilst the experiments of Dr. Redfern render it probable 
that the intermediate callus may result from a conversion or transforma- 
tion of the adjacent cartilaginous surfaces. Paget remarks, also, that 

1 Puel, Frac. des Cart. cost. Anvers, 1876. 

2 Ranking's Abstract, vol. i. p. 147, from the Lancet, Oct. 1844. 

3 Diagnosis of Visceral Lesions, 1869. 



FRACTURES OF THE CLAVICLE. 173 

the ossification extends to the parts of the cartilage immediately adjacent 
to the fracture. 

I have seen one example, which, after the expiration of more than 
one year, had not united. The fracture had occurred in the united car- 
tilages of the ninth and tenth ribs. The posterior fragment overlapped 
the anterior, and they played freely upon each other at each act of in- 
spiration and expiration. 

Treatment. — The treatment does not differ from that already recom- 
mended for fractured ribs. 



CHAPTER XIX. 

FRACTURES OF THE CLAVICLE. 

Fractures of the clavicle may be divided into those occurring 
through the inner, middle, and outer thirds. By the "outer third" is 
meant all that portion of the clavicle included between its scapular ex- 
tremity and the internal margin of the conoid ligament. • The remaining 
portion is intended to be divided equally into separate halves. The 
peculiarities of these several portions in respect to anatomical relations, 
liability to fracture, results, etc., will explain the propriety of the divi- 
sions. 

Causes. — If we except gunshot fractures, the clavicle is broken, in a 
large majority of cases, by a counter-stroke, such as a fall or a blow 
upon the extremity of the shoulder. Occasionally it is broken by a 
direct stroke, as when a blow aimed at the head is received upon the 
shoulder ; it is broken sometimes by the recoil of an overloaded gun, 
especially when the person lies upon the ground, with the butt of the 
gun resting upon the clavicle. 

Gibson has seen a case in which it was broken in a child at birth, by an 
ignorant midwife pulling at the arm, 1 and Dr. Atkinson has reported an example 
of intra-uterine fracture of the clavicle. 2 Gurlt has collected seven cases of 
intra-uterine fracture of the clavicle caused by external violence. 3 The clavicle 
may be broken by muscular action alone. A man standing upon the ground 
attempted to secure the braces of his carriage-top with his right arm, when he 
felt a sudden snap. Eight days after I found the right clavicle broken near its 
centre. The fragments were but slightly, if at all, displaced, but motion and 
crepitus at the point of fracture were distinct. A colonel of cavalry, about 
sixty years of age, mounting his horse, experienced a sensation as if something 
had broken, followed by acute pain in his left shoulder, and, on examination, it 
was found that the clavicle was fractured in the middle. The health of this 
gentleman had been impaired by repeated attacks of syphilis. W. E. White- 
head, U. S. N., has reported the case of a man, twenty-eight years old, who 
broke his left clavicle at the junction of the outer and middle thirds, while 

1 Gibson, Principles of Surg., sixth ed v vol. i. p. 272. 

2 Atkinson, Bost. Med. and Surg. Journ., July 2fi, 1860. 

3 Gurlt, Holmes's Surgery, ed. of 1870, vol. ii. p. 765. 



174 



FRACTURES OF THE CLAVICLE. 



attempting to raise himself to a platform eight feet high. The fracture was 
transverse, and unaccompanied with displacement. Malgaigne 1 has recorded 
three other examples of fracture of this bone from muscular action ; and Parker 
saw a case which was produced by striking at a dog with a whip. The bone, in 
the latter case, had been previously somewhat diseased, yet it united favorably. 2 
Of these seven cases, five occurred on the right side, and always near the middle 
of the bone, if we except one case reported by Malgaigne, in which the point 
of fracture is not mentioned. In neither case did the fragments become dis- 
placed, only as they were found, in some of the examples, inclined slightly for- 
ward. Gurlt has collected twenty cases of fracture from this cause. 3 Dr. Pooley 
reports an example of fracture of the clavicle in a child, supposed to have been 
due to muscular action, and which was the result of a fall upon the back.* 

[McKee, 5 of Tuscarora, Nev., had a case which occurred in a man while lifting 
a heavy weight; it was on the right side and near the middle of the clavicle; 
union had not taken place four months after, and there was evidence of a pseudo- 
arthrosis. Syphilis was denied.] 

Pathology. — It has already been observed, in speaking of partial frac- 
tures, that this bone suffers an incomplete fracture more often than any 
other, and that in such cases the lesion occurs generally in the middle 
third, or rather to the sternal side of the centre, and in a direction nearly 
or quite transverse. They are not usually accompanied with much dis- 
placement ; but if a displacement exists, it is a slight forward inclination 
of the fragments. Fractures which are complete occur mostly after the 
bones have become firm and unyielding. They are also generally oblique, 

seldom comminuted, still more rarely 
compound. The point of the clavicle 
at which a complete fracture usually 
occurs is at or near the outer end of 
the middle third, and a little to the 
sternal side of the coraco-clavicular 
ligaments, near where the trapezius and 
deltoid cease their attachments. It 
might be more exact to say that the 
fracture extends from this point down- 
ward and inward, toward the sternum, 
embracing one inch or less of its en- 
tire length. In some cases the obliquity 
is greater, and the amount of bone 
involved is much more considerable. 



Fig 




Why the bone should break more fre- 
quently at this point, especially in the 
adult and in the male, it is not difficult to 
understand. It is smaller here than else- 
where, and less supported by muscular and 
ligamentous attachments. At this point, also, the axis of the bone begins pretty 
abruptly to curve forward, and more abruptly in the adult and male than in 
the child and female. When, therefore, the clavicle is broken, as it usually is, 



Complete oblique fracture of clavicle. 



1 Whitehead, Pacific Med. and Surg. Journ., 1871. 

2 Parker, N. Y. Journ. Med., July, 1852. 

» Gurlt, Holmes's Surgery, ed. of 1870, vol. ii. p. 765. See also paper by M. Deleus on 
Fractures of the Clavicle from Muscular Action, in Archives Generates, March, 1875. 

4 J. H. Pooley, Prof. Surg. Starling Med. Coll., Columbus, Ohio. • A Clinical Lecture, 
1877. 

5 Occidental Med. Times, 1890. 



FRACTURES OF THE CLAVICLE. 175 

by a counter-stroke, the force of the blow, conveyed from the shoulder through 
the outer portion of the bone, is suddenly arrested, and expends itself upon the 
point where the direction of the axis is changed. In a record of 157 fractures, 
including partial and comminuted, and not including gunshot fractures, 127 
have occurred through the middle third ; and, with the exception of the partial 
fractures, the fracture has in nearly all of the cases taken place near the outer 
end of this third. Four have occurred through the inner third, three of which 
were within one inch of the sternum ; and seventeen through the outer third. A 
more practical analysis can be based, however, upon the point of fracture with 
reference to its cause ; and I have never, but once, seen a complete fracture of 
this bone, in the adult, produced clearly by a counter-stroke, which was not 
near the outer end of the middle third. 

When the fracture is in any portion of the middle third, the direction 
of the displacement is almost uniformly the same. The sternal fragment 
is slightly lifted by the action of the clavicular portion of the sterno- 
cleido-mastoid muscle, notwithstanding the resistance of the rhomboid 
ligament, the pectoralis major, and the subclavius muscles. On the 
other hand, the acromial fragment is dragged downward by the weight 
of the arm, aided by the conjoined action of a portion of the pectoralis 
major and the latissimus dorsi, feebly resisted by the trapezius and other 
muscles from above ; by the action of the same muscles, aided by the 
pectoralis minor, and perhaps by some portion of the subclavius, it is 
drawn toward the body, diminishing thereby the axillary space ; while 
by the preponderating strength of the pectoralis major and minor, the 
acromial end of the fragment, with the shoulder, is drawn forward ; the 
sternal end of the same fragment being rather displaced backward, and 
at the same time resting at a point somewhat elevated above the acro- 
mial end. 

Desault has recorded one example of an overlapping by the elevation of the 
acromial fragment over the sternal. 1 Syme has mentioned a case of this kind 
which he had seen. 2 Gueretin, Malgaigne,* and Stephen Smith have each 
reported an example. 4 In Stephen Smith's case the bone was broken through 
the outer third, and transversely; the overlapping, to the extent of one inch, 
remained after the cure was completed. M. O'D., set. forty years, was admitted 
to the Charity Hospital with a single fracture of the clavicle, near its middle, 
caused two weeks before, by a fall on the shoulder. The sternal fragment was 
lying beneath the acromial, and in this position it finally united. 

In nearly all cases of oblique fractures occurring through the middle 
third there follows immediately an overlapping, varying from one-quarter 
of an inch to an inch, and sometimes, though very rarely, exceeding this ; 
the average shortening being about half an inch. 

There is a specimen in the Dupuytren Museum, in which the shortening 
equals one-third of its entire length. 

Transverse fractures, wherever they may occur, whether in children 
or adults, are seldom found displaced, at least in the direction of the 
axis of the bone, and they unite usually without shortening or de- 
formity. 

1 Desault on Frac, op. cit., p. 16. 2 Amer. Journ. Med. Sei., vol. xvii. p. 251. 

3 Malgaigne, op. cit., p. 461. * New York Journ. of Med., May, 1857. 



176 FRACTUEES OF THE CLAVICLE. 

A lady, aged eighty years, fell down a flight of stairs, breaking the right clav- 
icle transversely, about one inch from the sternum. Motion and crepitus were 
distinct, but there was scarcely any displacement. No dressings were applied, 
but she was directed to keep quiet in bed, and upon her back. In the usual 
time the fragments had united, without deformity. A man fell backward from 
a wagon, breaking the collar-bone near the middle. The fragments were mov- 
able, but not displaced. He was treated successfully, and without any resulting 
deformity, by simple confinement in the recumbent posture during a few days, 
and after this by suspending the arm in a sling, while he was permitted to walk 
about. A young man, aged twenty-six years, fell while wrestling, and broke the 
clavicle at the outer end of the middle third. There was some displacement at 
first, but the fragments, being reduced, were found to support themselves. A 
cross, secured with straps, was applied to the back, and on the twenty-eighth 
day the union was complete, and without deformity. A child, aged three years, 
fell about six feet, striking upon his shoulder. I found the left clavicle broken 
off completely, about one inch from its scapular end. Crepitus and motion were 
distinct, but the fragments were not displaced. The arm was placed in a sling, 
and on the seventh day both motion and crepitus had ceased. The cure was 
accomplished without any degree of displacement. Stephen Smith, of New 
York, has met with two examples of transverse fractures without displacement, 
in a hospital record of eleven cases. Bichat says, Desault has frequently ob- 
served the same, it having been seen three times at Hotel Dieu, in the course of 
the year 1787. Desault thinks, also, that sometimes the fracture, taking place 
obliquely upward and inward, the usual form of displacement is prevented, and 
apposition is preserved. In nearly all of the examples of partial transverse frac- 
tures, occurring in children, seen by me, there has been no longitudinal displace- 
ment. 

If the fracture is near the sternum, and within the fibres of the costo- 
clavicular ligaments, as in the case of the old lady just cited, the dis- 
placement is inconsiderable. 

I have seen one other similar case, in an adult also. Lonsdale mentions a case, 
in a child three years old, which he regarded as a separation of the epiphysis, the 
point of fracture being half an inch from the sternum. Malgaigne mentions 
two other examples, in one of which the fracture was so near the sternum that 
it was difficult to say whether it was not a partial dislocation. The displacement 
was only trivial. But the only two specimens contained in the Dupuytren 
Museum offer a considerable displacement, and in both the external fragment is 
thrown downward and forward. 

A similar specimen was from a patient in Bellevue Hospital. The fracture 
was occasioned by a fall upon the shoulder, and extended from the sterno-clavic- 
ular articulation upward and outward one inch and a half. The fragments 
were overlapped three-quarters of an inch, and were firmly united. A case is 
reported from Mt. Sinai Hospital, in this city, of a fracture of the clavicle in 
an adult, at a point about one inch from the sternum. The inner fragment was 
drawn, by the action of the sterno-cleido-mastoid muscle, into a vertical position, 
and the outer was drawn down upon the chest. It became apparent that replace- 
ment could not be effected without division of the muscle ; and, inasmuch as the 
displacement caused no inconvenience, it was permitted to remain as it was 
found. 1 

With regard to the amount of displacement usually attendant upon 
fractures near the outer end of the bone, surgical writers have generally 
united in declaring that it was in a majority of cases very inconsiderable, 
while some have even affirmed that there would be found no displacement 
whatever. 

Neither of these opinions, according to the observations of Robert Smith, of 
Dublin, is strictly correct. He has examined eight specimens of fracture of the 

1 New York Med. Journ., Jan. 1877, p. 48. 




FRACTUKES OF THE CLAVICLE. 177 

outer extremity of the clavicle, contained in the museum of the Richmond 
Hospital School of Medicine ; three of which were broken between the conoid 
and trapezoid ligaments, and are united with very little displacement, whilst the 
remaining five, broken beyond the trapezoid ligament, present a very marked 
deformity. The following is a summary of the conclusions to which he has 
arrived : " When the clavicle is broken between the two fasciculi of the coraco- 
clavicular ligament, there is seldom any displacement of either fragment, and 
always much less than in fracture of any other portion of the bone. When dis- 
placement does occur, it is usually limited to a slight alteration in the direction 
of the bone, by which the natural convexity of this portion of the clavicle is 
increased. The explanation of which facts is found in the attachments of the liga- 
ments from below to the two fragments, and in the action of the trapezius from 
above, by which they are antagonized. But the case is very different when the 
bone is broken external to the trapezoid ligament. Here the coraco-clavicular 
ligaments can have no direct influence upon the outer fragment, which is dis- 
placed now partly by muscular action, and partly by 
the weight of the arm, the sternal end of the outer 
fragment being" drawn upward by the clavicular por- 
tion of the trapezius, while, by the action of the mus- 
cles passing from the chest, the entire outer fragment 
is drawn forward and inward, so as to bring some- 
times its broken surface into contact with the anterior 
surface of the inner fragment, and placing it nearly 
at right angles with this fragment, in which position 
it is generally united. The displacement in this di- F ™cture outside of trape- 
rection, rather than any degree of overlapping, ex- zoid ligament. United. 
plains also the shortening which existed in all of 

these cases, varying in the different specimens from half an inch to one inch, 
and averaging about three-quarters of an inch." In my own experience, a frac- 
ture occurring in a child three years old, within one inch of the acromial end, 
probably between the ligaments, was never displaced at all ; a second, and third, 
occurring in adults, presented no displacement. Two cases were displaced each 
one-quarter of an inch, and two cases half an inch; these four latter cases 
occurred in adults, and always within an inch of the acromial end of the bone. 
In one of these last examples, the inner fragment was rather behind than above 
the outer fragment. 

It has happened to rue only six times to meet with a comminuted frac- 
ture of the clavicle, except in cases of gunshot injuries, all of which 
fractures occurred through some portion of the middle third of the bone ; 
the intercepted fragments being from one inch to one inch and a half in 
length, and lying obliquely, or, as in one case observed by me, at nearly 
a right angle with the main fragments. A compound fracture of this 
bone I have not seen, except as the result of a gunshot injury, although, 
in many cases, the sharp point of an oblique fracture has seemed just 
ready to penetrate the skin. 

One case is reported as having been presented at St. Bartholomew's Hospital. 
It occurred in a boy fourteen years old, and was produced by his having been 
drawn into some machinery while it was in motion. 1 Two similar cases are re- 
ported from the New York Hospital, as having been observed during the last 
ten years preceding the date of the report. The whole number of fractures of 
the clavicle during this period was 191. 2 Lente also mentions a case, seen by 
himself, occasioned by the fall of a derrick upon the shoulder. 

A double fracture, or a simultaneous fracture occurring in both clavi- 
cles, seldom occurs. 

1 London Med. Gaz.. vol. ii.p. 382. 

2 New York Med. Times, March 16, 1861. 

12 



178 



FRACTURES OF THE CLAVICLE 



I have recorded two cases [four fractures, three of which are incomplete), both 
occurring in young boys. 1 Dr. Burr, of Binghamton, N. Y., has reported a 
case which occurred in a man about fifty years old. 2 To these M. Polaillon has 
added eight others gathered from various sources. Malgaigne says it has only 
happened once in 2358 cases at the Hotel Dieu, arid he can recollect only five 
other examples. And of 158 cases of broken clavicles reported from the New 
York Hospital, it is stated to have occurred in only four. 

[White, 8 of Philadelphia, reports a case of simultaneous fractures of both 
clavicles as the result of a fall from a railroad car. The patient was treated in the 
recumbent position with sand-bags applied to his head to prevent movement. 
Good union was obtained, with no more than the average amount of deformity.] 

Symptoms. — In all cases of complete fracture with displacement, no 
difficulty will be experienced in deciding upon the nature of the injury. 

The patient is found generally 
leaning toward the injured side, 
whilst the opposite hand sustains 
the elbow of the same side, to 
prevent its dragging downward. 
The shoulder falls downward, for- 
ward, and inward ; whilst, at the 
same time, the line of the bone is 
interrupted by the sharp and pro- 
jecting point of the sternal frag- 
ment. If the fracture is the re- 
sult of a direct blow, a swelling 
and discoloration may be seen at 
the seat of fracture ; but if it is 
the result of a counter-stroke, we 
must look to the top or point of 
the shoulder for the signs of a 
contusion. The patient also ex- 
periences pain when an attempt 
is made to raise the arm at a right 
angle with the body, and especi- 
ally in attempting to carry the arm across the body, by which the ends 
of the broken clavicle are driven into the flesh. 




Complete fracture — Oblique; at junction of 
outer and middle thirds. (From nature.) 



In two cases of oblique fracture, accompanied with displacement, occurring 
in the middle third of the bone, I have "particularly noticed that the patients 
could easily lift the hands to the head, and in one of these cases the patient, a 
boy, fourteen years old, raised his arm perpendicularly over his head. Such 
exceptions are not very uncommon. 

Crepitus can be detected sometimes by simply pressing down the 
sternal fragments, but it is almost always present when we draw the 
shoulders forcibly back, so as to bring the broken fragments into more 
perfect contact. If there is no displacement, still crepitus may gener- 
ally be discovered by grasping the bone between the thumb and fingers, 
and moving it gently up and down, or by slight pressure upon the point 
of fracture. When the fracture occurs close to the acromial extremity, 



1 Report on Def. after Frac, Cases 5, 6, 10. 
3 Univ. Med. Mag., Jan. 1890. 



Burr, Med. Rec, May 6, 1882. 



FRACTURES OF THE CLAVICLE. 



179 



Fig. 80. 



external to the coraco-clavicular ligaments, quite frequently there is no 
perceptible or marked displacement, and its diagnosis will require, there- 
fore, more care and attention on the part of the surgeon. 

Prognosis in this fracture deserves especial attention. In no other 
bone, except the femur, does a shortening so uniformly result. 

Of seventy-two complete fractures only sixteen united without shortening ; 
and of twenty-seven simple, oblique, complete fractures, which occurred at or 
near- the outer end of the middle third, only one united without shortening, and 
in this case the patient was but fifteen years old, and the fragments were never 
much displaced. Six cases of complete transverse fracture, occurring at the 
same point, united without shortening. 

The shortening, after the union is consummated, varies from one- 
quarter of an inch to one inch or more ; and the fragments are almost 
always, especially when the fracture is through the middle third, found 
lying in the position in which we have described them to be at the first ; 
the outer end of the inner fragment being above, and often a little in 
front of, the outer ; sometimes, espe- 
cially in lean persons, and when the 
fractures are very oblique, present- 
ing a sharp and unseemly projection. 
The greatest amount of shortening 
is generally found in those fractures 
which occur through the middle 
third, or between the rhomboid and 
coraco-clavicular ligaments. In frac- 
tures near the sternal end, within 
the region occupied by the rhomboid 
ligament, there is usually very little 
permanent displacement. The same 
is true when the fracture is at the 
acromial end, and between the fas- 
ciculi of the coraco-clavicular liga- 
ments ; but if the fracture is beyond 
these ligaments, near the acromial 
end, the final displacement and de- 
formity may be very great. The 

presence of a small amount of ensheathing callus soon after the cure is 
completed, sometimes increases the deformity. It is rarely seen to en- 
circle the bone completely, and occasionally it appears to be most abund- 
ant in the direction of the salient points of the fracture, that is, above 
and below ; so that, unless the examination is made with care, the pro- 
jecting points of callus which remain, sometimes after many years, may 
be easily mistaken for an intercepted fragment turned at right angles to 
the axis of the bone. 




Comminuted fracture. — United. 
(From nature.) 



Robert Smith has observed, also, that in cases of fracture external to the 
conoid ligament, osseous matter is freely formed upon the under surface of each 
fragment, but there is seldom any deposited upon the upper surface of either. 
These osseous growths, occupying the situation of the coraco-clavicular liga- 
ments, frequently prolong themselves as far as the coracoid process, and in some 



180 FRACTURES OF THE CLAVICLE. 

cases to the notch of the scapula. Still less frequently these osteophytes become 
fused with the coracoid process, and a true ankylosis exists. 

In comminuted fractures the intercepted fragments generally fall off 
from the line of the other fragments, and cannot easily be restored. The 
clavicle, being a spongy and vascular bone, usually unites with great 
rapidity, generally w T ithin twenty days. 

In the fourth example of transverse fracture already mentioned as having 
been seen by me, the union seemed to be tolerably firm in seven days. Wallace 
reports one case from the Pennsylvania Hospital, which was cured in eight days, 
and another in nine days. 1 Velpeau says the clavicle will unite in from fifteen 
to twenty-five days ; Benjamin Bell in fourteen; Stephen Smith has seen it firm 
in fifteen days. 

Whatever may be the degree of displacement, or the condition of the 
system, unless in a case of gunshot fracture, it is very seldom that it 
refuses to unite altogether, or that the union is ligamentous. In Muhlen- 
berg's tables of 656 cases of delayed and non-union of long bones, there 
is but one example of non-union of the clavicle. And in the few cases 
found upon record of a ligamentous union, the functions of the arm do 
not seem to have suffered any serious ultimate injury, as the following 
example will illustrate : 

An Irish laborer fell from a horse and broke his left clavicle, at the outer end 
of the middle third ; he continued at work, nor from that day forward did he 
cease from his work. The clavicle presented the same deformity which many 
other similar fractures present after what is usually termed successful treatment, 
except that it was not united by bone. The outer end of the inner fragment 
rode upon the inner end of the outer fragment half an inch. The ligament 
uniting the two extremities was so long and firm that it could be distinctly felt, 
and the fragments moved upon each other with great freedom. We ascertained 
by experiment that with his left arm he could lift as much, within three ounces, 
as he could with his right, and he was not himself conscious of any difference. 
The muscles of the left arm seemed as well developed as those of the right. I 
examined in the Charity Hospital, New York, a fracture of the left clavicle, 
which had united only by ligament; it had occurred at about the junction 
of the outer fourth with the inner three-fourths. No treatment had ever 
been adopted. The ligament was quite long, and the fragments moved freely 
upon each other, yet the arm was nearly as strong and as useful as before. 
Chelius also refers to two cases mentioned by Gurdy and Velpeau, in which, 
although an artificial joint remained, the use of the limb was but little impaired. 2 
In a case of compound and comminuted gunshot fracture reported by Ayres, of 
Brooklyn, the recovery was remarkable. The clavicle was so extensively com- 
minuted that before the wound closed over one-third of the bone had escaped, 
and yet at the end of one year from the time of the accident the shoulder was 
perfectly symmetrical with its fellow, without drooping or falling forward. Dr. 
Ayres thinks that all of the clavicle which was lost had been reproduced. 

A partial paralysis, with atrophy of the muscles of the arm, accom- 
panied, also, with more or less rigidity and contraction of the muscles 
both of the arm and forearm, is, according to my observation, a more 
frequent result of these fractures. 

Mr. Earle has recorded a case of comminuted fracture of the clavicle, in which 
the nerves converging to form the axillary plexus were so much injured that 

1 Araer. Journ. Med. Sci., vol. xvi. p. 115. 

2 Chelius, Amer. ed., vol. i. p. 603. 



FKACTUKES OF THE CLAVICLE. 181 

paralysis of the arm ensued ; and it was noticed as an interesting fact, that the 
patient could not afterward put her hand into even moderately warm water 
without the effects of a scald being produced, characterized by vesication, red- 
ness, etc. 1 Desault saw a case at Hotel Dieu, in which, although the clavicle 
was not broken, the force of the blow upon the clavicle was sufficient to produce 
a severe concussion of the brachial plexus and paralysis of the arm. A timber 
had fallen from a building, striking upon the external part of the left clavicle. 
A considerable wound, followed by swelling, pointed out the place on which the 
blow had been received. No apparatus was applied, and on the third day a 
numbness and partial loss of the power of motion occurred in the arm of the 
affected side. Soon afterward an insensibility came on, and by the seventh 
day the paralysis of the arm was complete. It was not until after a tedious 
treatment that the limb recovered in part its original strength. In Case 23 of 
my report to the American Medical Association, which was followed by paralysis 
of the opposite arm, and spinal curvature, one cannot avoid a suspicion that the 
apparatus, Brasdor's jacket, contributed somewhat to the unfortunate result. No 
axillary pad was employed, but the straps over each shoulder were buckled so 
tight that he was compelled to incline his head constantly to the right side. 
He was unable to lie down, and could only incline in a half-sitting posture. 
This treatment was continued four weeks ; and two months after its removal the 
paralysis and spinal distortion commenced. 

Gibson relates a remarkable instance of this kind. A young man was struck 
on the clavicle by the falling limb of a tree, breaking it into numerous pieces, 
and bruising the parts so severely as to give rise to violent inflammation. 
"The fragments had been driven behind and beneath the level of the first rib, 
and so compressed the plexus of nerves as to wedge them into each other, and 
by the subsequent inflammation to blend them inseparably together. Complete 
paralysis and atrophy of the whole arm ensued." 2 

While there is the possibility of a paralysis resulting from concussion 
of the axillary nerves, produced by a blow upon the clavicle, and of a 
paralysis resulting from a direct injury inflicted by the points of the 
fragments upon this plexus in certain very badly comminuted fractures, 
these conditions will not satisfactorily explain all of the examples in 
w T hich paralysis has followed simple fractures. In some cases it is no 
doubt due rather to the injudicious mode of using an axillary pad, by 
means of which the arm is converted into a powerful lever, and thus the 
brachial nerves are made to suffer from compression along the inner side 
of the arm itself. The paralysis is, therefore, sometimes due to the 
treatment alone, and not to the original injury. 

[Chavier, 3 in an article on nervous affections following fractures of the clavicle 
by indirect cause, regards many of these cases due to a neuritis which extends 
to the nervous centre.] 

[M. Blum 4 reports a case of fracture of the clavicle followed by atrophy of the 
arm, and a painful condition of the nerves, which he attributed to pressure of 
an exuberant callus. This was excised partially with slow recovery of the 
limb.] 

Parker, of New York, declares that he has seen one patient who had lost the 
use of his arm from the pressure upon the nerves by the wedge-shaped pad over 
which the limb was confined in order to pry the shoulder outward. Stephen 
Smith mentions a case of partial paralysis from the same cause. 5 A similar case 
has come under my own observation. A lady was thrown from her carriage, 
breaking the right clavicle obliquely at the outer end of the middle third. 
During the first three weeks the arm was dressed with Fox's apparatus, which 

1 S. Cooper's First Lines, fourth Amer. ed., vol. ii. p. 323. 

2 Gibson, op. eit., 6th ed.. vol. i. p. 271. 

3 Gaz. Med de Paris, 1889. * Eev. Clin. Chirurg., 1888. 
5 Stephen Smith, New York Journ. of Medicine, May, 1857. 



182 FRACTURES OF THE CLAVICLE. 

was at no time particularly painful. She was then placed under the care of 
another surgeon, who, finding the fragments overlapped, applied very firmly a 
figure-of-8 bandage, with an axillary pad, securing the arm snugly to the side of 
the body ; hoping by these means to restore the fragments to their place. The 
pain which followed was excessive, and, notwithstanding the free use of ano- 
dynes, it became so insupportable that at the end of fourteen hours the dressings 
were removed by another surgeon, and Fox's apparatus again substituted. 
These were also applied much more tightly than at first, and during the four 
weeks longer that they remained on, repeated attempts were made to reduce the 
fragments. Forty-eight days after the accident, she consulted me. The clavicle 
was then united, and overlapped half an inch. The whole arm was swollen, 
painful, and very tender, with total inability to move it. I removed all the 
dressings, and, during the time she remained under my care, in a private room 
at the hospital, there was a gradual improvement in the condition of her arm, 
in respect to swelling and tenderness, but the paralysis did not much abate. 

Erichsen thinks he has seen one case of comminuted fracture, produced 
by a direct blow, in which the subclavian vein was ruptured ; great ex- 
travasation of blood resulted, and the arm was threatened with gangrene. 
The patient having recovered, however, the diagnosis could not be deter- 
mined by actual dissection. 1 

M. Maunoury, of Chartres, met with a similar case, in which, while attempting 
to tie the vein, the patient died in consequence of the admission of air. 2 J. W. 
Ogle has reported a case of wound of the internal jugular caused by a fragment 
of a broken clavicle. 3 

Dupuytren stated that he had seen two examples of aneurism conse- 
quent upon fracture of the clavicle. Follin says that Sir Robert Peel 
having been thrown from his horse, had his left clavicle broken, and 
death ensued, in consequence, it was believed, of a traumatic aneurism 
resulting from a wound of an arterial vessel. 4 

" M. More reported to the Surgical Society, in 1876, a case of fracture of the 
clavicle, in which M. Verneuil and the majority of the members admitted the 
existence of a partial rupture of the subclavian artery. An old man had his 
clavicle broken in consequence of direct violence. The apparatus (bandage and 
axillary pad) was only applied on the third day ; on the same evening pains and 
formications occurred in the hand, which, the next day, presented a bluish 
appearance in color; in addition, no pulsations in the radial or ulnar artery 
could be felt. In view of these accidents, the apparatus, already loose, was 
removed. It took two months for the limb to regain its normal strength and 
appearance; but the pulsations in the vessels did not return until after the lapse 
of eight months. Indeed, this case is not absolutely conclusive, and, notwith- 
standing the great authority of the surgeons who admitted the rupture of an 
artery, it is fair to ask if the pressure produced by the axillary pad was not the 
real cause of all these accidents." 5 To these judicious comments of M. Pbinsot 
in reference to the case of M. More, I wish to add my opinion, that there is good 
reason for believing, if a vessel were torn, it was done by the surgeon in his 
attempts to restore the fracture to place; and that if it was not torn, the violent 
and injudicious efforts of the surgeon to maintain it in place by an axillary pad, 
bandages, etc., might explain the obliteration of the arterial circulation. The 
lesson is not, in my opinion, to be overlooked by those who so assiduously 
attempt, by similar means, to accomplish what, in most cases, is impossible. 

1 Erichsen, Surgery, Amer. ed., p. 205. 

2 Maunoury, Prog. Med., Avril, 1882. 

3 Ogle, Brit. Med. Journ., July 26, 1872. 
* Follin, Path. Ext., t. 2, p. 849. 

5 More, Rev. des Sci. Med., t. 10, p. 235. Poinsot. 



FRACTUKES OF THE CLAVICLE. 183 

Fracture of the clavicle may also be complicated with, a wound of the 
lung and with extensive emphysema. 

M. Polaillon has published three cases of this kind taken from Vigaroux, 
Yelpeau et Huguier. Very recently, M. Gibier de Savigny reported a case of 
fracture of the clavicle in which the external fragment had perforated the lung. 
Considerable emphysema supervened, and the patient recovered almost without 
treatment ; but a pseudarthrosis remained. 1 

Since among surgeons some difference of opinion seems to exist as to 
the practicability of overcoming the displacement in certain fractures ot 
the clavicle, it is proper that I should defend the accuracy of my own 
observations by a reference to the observations of others. 

In nine of eleven cases reported by Stephen Smith, one of the surgeons at 
Bellevue Hospital, Xew York, more or less deformity remained after the cure 
was completed. 2 Chelius remarks: " Setting of this fracture is easy, yet only 
in very rare cases is the cure possible without any deformity." . ..." It 
is considered, also, that the close union of the fracture of the collar-bone depends 
less on the apparatus than on the position and direction of the fracture (there- 
fore, in spite of the most careful application of this apparatus, some deformity 
often remains)." 3 Velpeau, in a lecture given in 1846, and published in the 
Gazette des Hdpitaux, declares that with all the bandages imaginable, in the case 
of an oblique fracture at the junction of the outer third with the inner two- 
thirds, we cannot prevent deformity. Vidal observes : " Fracture of the clavicle 
is almost always followed by deformity, whatever may be the perfection of the 
apparatus and the care of the surgeon." 4 

M. Mayor, of Lausanne, thinks that up to this day no successful mode of 
treatment has been devised. "Here everything appears as yet so little deter- 
mined, that each day sees some new proposition and different procedures," etc. 
Says M. Malgaigne : "The prognosis, considering the trivial character of this 
fracture, is sufficiently difficult. For, little as may be the displacement, the 
surgeon ought not to promise a reunion without deformity; and certain success- 
ful results, proclaimed from time to time, betray, on the part of those who relate 
them, the most extravagant exaggerations." 5 M. Xeleton having spoken of the 
various plans which have been suggested to retain this bone in place, and of 
their inefficiency, comes at last to speak of the handkerchief bandage of M. 
Mayor, and remarks: "This apparel is very simple; but neither will it remedy 
the overlapping." . ..." Of all the apparels which we have passed in 
review, there is, then, not one which fills completely the three indications usually 
present in the fracture of a clavicle. None of them oppose the displacement ; 
they have no effect, with whatever care they may be applied, but to maintain 
immobility in the limb. We think, then, that it is useless to fatigue the patient 
with an apparatus annoying, and, perhaps, even painful; a simple sling, secured 

upon the sound shoulder, will be sufficiently severe If there is a 

tendency to displacement, the consolidation will be effected with a deformity 
more or less marked ; but since this deformity is inevitable, at least with adults, 
whatever may be the apparel which we employ, it is evident that the apparatus 
which causes the least constraint ought to have the preference. We may remark, 
farther, that this union with deformity in nowise impairs the free exercise of all 
the movements of the members." 6 Dr. Gross says that, according to his experi- 

1 Polaillon, Die. Encyc. des Sci. Med., t. 17, p. 695. French ed. of this treatise, p. 220, 
note by Poinsot. 

2 :N"ew York Journ. Med , May, 1857, p. 382. 

3 System of Surgery. By J. M. Chelius, of Heidelberg, with notes by South. First 
Amer. ed , vol. i. pp. 603, 605. 

4 Vidal (de Cassis), Paris ed., vol. ii. p. 105. 

5 Traite des Fractures et des Luxations, par J. F. Malgaigne, tome premier, p. 473. 
Paris ed., 1847. 

6 Elements de Pathologie Chirurgicale, par A. Xelaton, tome premier, p. 720. Paris ed., 
1884. 



184 FRACTURES OF THE CLAVICLE. 

ence, " fractures of the clavicle are seldom cured without more or less deformity, 
whatever pains may be taken to prevent it." 1 Roser says: " The treatment of 
fractures of the clavicle is, after all that has been said, very imperfect; and it is 
very often the case that, after a most careful treatment, some deformity will 
remain, such as protrusion of the inner fragment, crossing of the fragments, 
and consequent shortening." 2 Bryant says: " Deformity almost always exists in 
spite of treatment." 3 

Treatment. — If evidence were needed beyond that which has been 
furnished, of the difficulty of bringing to a successful issue the treat- 
ment of this fracture, it might be supplied, satisfactorily, by a reference 
merely to the immense number of contrivances which have been at one 
time and another recommended. The indications for a complete restora- 
tion of the outer fragment, which alone is supposed to be much displaced, 
are to carry the shoulder upward, outward and backward. But as to 
the means by which these indications can be most easily, if at all, accom- 
plished, the widest differences of opinion have prevailed. On the one 
hand, no invention has wanted for advocates; on the other hand, no 
method has escaped its equivalent of censure. 

The first method seems to have been posture. The earliest physicians 
recommended the recumbent posture. 

Hippocrates and Celsus, followed by Dupuytren, Flaubert, Lizars, Pelletan, and 
others, directed patients to lie upon their backs, with little or no apparatus. S. 
Cooper and Dorsey recommend that patients should be confined in this position 
during most of the treatment. Dr. Lente intimates that a similar plan was at 
one time adopted in the New York City Hospital. He states : " But this result " 
(angular deformity) "rarely happens when the patient has strictly followed the 
directions of the surgeon, as to position especially, for it is by position, more 
than by any other remedial means, that a good result is to be effected." Dr. 
Post mentions a case treated in this manner, which terminated with very little 
deformity; 4 and I have myself treated many cases by this plan, with more than 
average success. Dr. Edward Hartshorne, of Philadelphia, has published a 
very ingenious argument in favor of the supine position, in which he seems to 
have demonstrated that the special efficacy of this plan depends upon the pres- 
sure made against the angle of the scapula. In order to accomplish this, and 
to place the scapula in the position most favorable for the reduction of the 
clavicle,. the back should rest upon a broad, firm, and unyielding mattress, and 
not upon a pillow between the shoulders, which latter has the effect rather to 
defeat than to promote the indication ; the head should be slightly raised so as 
to relax the sterno-cleido-mastoid muscles and somewhat extend the trapezius ; 
the arm and forearm of the injured side should be flexed, resting across the 
chest, with the hand reaching over the sound shoulder, or it should be placed at 
right angles with the body. The absolute immobility required by the posture 
treatment must always limit its application, and render its general employment 
impossible. Dr. J. A. Packard, of Philadelphia, regards the scapula, also, as 
the bone upon which the restoration of the clavicle chiefly depends; and he 
finds in the serratus magnus the especial obstacle to this restoration. 5 

In order to carry the shoulders back, a figure-of-8 has been preferred 
by some and condemned by others. To this apparatus many surgeons 
add some form of back-splint, extending from acromion to acromion, 
against which the shoulders may be properly secured. 

1 Gross, System of Surgery, vol. i. p. 954, 1872. 

2 W. Roser, Handbuch der Anatomischen Chirurgie, 6 Aufl. Tubingen, 1372. 

3 Bryant, Practice of Surgery, London, 1872, p. 927. 
* N. Y. Journ of Med., vol. ii. p. 226. 

5 Packard, New York Journ. of Med., 1867. 



FRACTURES OF THE CLAVICLE. 



185 



Fig. 81. 




Parker says that splints of this kind, with a figure-of-8 bandage, are "better 
than all the apparatus ever invented," whilst Mr. South gives his testimony in 
relation to all dressings of this sort as follows : "I do not like any of the appa- 
ratus in which the shoulders are drawn back by bandages, as these invariably 
annoy the patient, often cause excoriation, 
and are never kept long in place, the per- 
son continually wriggling them off to relieve 
himself of the pressure." 

Again, others bring the elbow a little 
forward, and then lift the shoulder up- 
ward and backward ; or carry the elbow 
still farther forward, so as to lay the 
hand across the opposite shoulder. 
Gruillou carries the hand and forearm 
behind the patient, and then proceeds 
to lift the shoulder to its place. Moore, 
also, recommends that the elbow shall 
be carried back. 



Thus Desault, Fox, and Wattman accom- 
plish the indication to carry the shoulder 
back, by lifting the humerus, with the 
elbow in front of the body ; whilst Guillou Figure-of-S. 

and Moore accomplish the same indication 
by lifting the humerus when the elbow is a 

little behind the body. Chelius also says: "The elbow, as far as possible, is to 
be laid backward on the body." Sargent, who believes that with Fox's appa- 
ratus "the occurrence of deformity is the exception," and not the rule, and 
prefers it to all others, has treated three cases by Guillou's method, and is per- 
fectly satisfied with its operation. Hollingsworth, of Philadelphia, has also 
treated one case successfully by Guillou's method, and adds his testimony in its 
favor. Several surgeons think they have obtained equal success with Moore's 
apparatus. 

But how shall we explain these equal results from opposite modes of 
treatment ? Is the indication to carry the shoulders back, which Fox 
sought to accomplish by pressing the elbow upward and backward, as 
easily attained by pressing the elbow upward and forward ? Or are we 
not compelled to infer that there has been some mistake as to the precise 
amount of good accomplished by the apparatus in either case ? More- 
over, Coates, 1 Keal, and others instruct us that the only safe and proper 
position for the humerus is in a line with the side of the body, and that 
it must neither be carried forward nor backward. 

Many surgeons, as Paulus oEgineta, Boyer, Desault, Pecceti, Liston. 
Fergusson, Samuel Cooper, Erichsen, Miller, Skey, Levis, recommend 
an axillary pad ; whilst others of equal reputation deny its utility or 
affirm its danger. 

Dr. Parker has seen one patient in whom paralysis of the arm resulted from 
the pressure upon the brachial nerves, in the attempt "to pry the shoulder out." 

Prof. E. M. Moore, 2 of Rochester, has called attention to what he 
terms the " figure-of-8 from the elbow," which renders tense the clavicular 



1 Coates, Amer. Journ. Med. Sci., vol. xviii. p. 62. 

2 Transactions N". Y. State Med. Soc, 1871. 



186 



FEACTURES OF THE CLAVICLE. 



fibres of the pectoralis major, and at the same time draws the scapula 
backward toward the spine ; it overcomes the action of the sterno-cleido- 
mastoid, which lifts the sternal fragment, and draws the acromial frag- 
ment outward and upward. 



Fig. 82 




Moore's apparatus. Back view. 



Moore's apparatus. Front view. 



These ends are accomplished by placing the extremity of the middle ringer of 
the broken arm upon theensiform cartilage, with the forearm and elbow pinned 
back and against the body. In order to secure the arm in this position, Dr. Moore 
uses a shawl or piece of cotton cloth, which, when folded like a cravat, eight inches 
in breadth at the centre, should be about two yards long. Placing this at the 
centre across the palm of the surgeon, he seizes with his hand the elbow of the 
patient which corresponds with the broken clavicle. The two ends of the 
bandage hang to the floor. The one falling inward toward the patient is carried 
upward, in front of the shoulder, and over the back, making a spiral movement 
in front of the shoulder. This is intrusted to an assistant. The outer end is 
then carried across the forearm, behind the back, over the opposite shoulder, 
and around the axilla. This meets the other end, which may be carried under 
the axilla and over the shoulder of the opposite side, thus making the figure 
eight (8) turn, around the sound shoulder. This twist, it will be seen, makes 
also the figure eight (8) turn, around the elbow of the affected side. The fore- 
arm should be sustained by a sling which raises it to an acute angle in order that 
gravity may assist in moving the whole arm backward. This is best done by a 
simple strip three or four inches wide, which may be pinned to the shawl at the 
shoulder, or by a sling across the opposite shoulder and behind the back ; the 
former is much to be preferred. Any tendency on the part of the shawl to slide 
from the shoulder may be arrested by a pin thrust at the crossing. The shawl 
at the elbow is kept in place by folding the upper part that fits the arm and 
securing it by a pin. This makes a sort of cup for the elbow. 

The principle upon which this dressing is constructed appears sound ; 
but in the five or six cases in which it has been employed it failed to 



FRACTURES OF THE CLAVICLE. 



187 



accomplish any more than is accomplished by many other forms of 
dressing. It is especially liable to become disarranged, and to cause 
excoriations in the sound axilla ; in this respect being quite as liable to 
criticism as the ordinary figure-of-8. 

Dr. Lewis A. Sayre, of this city, has employed an apparatus to render 
tense the clavicular attachments of the pectoralis major, and thus secure 
more effectually the depression of the 
sternal fragment, while at the same time 
the shoulder is lifted and carried back. 



Fig. 84. 



Two strips of adhesive plaster are prepared, 
each about three and a half inches wide, for 
an adult; one long enough to encircle, first 
the arm, and then the body completely ; the 
other of sufficient length to reach from the 
sound shoulder, over the point of the elbow 
of the broken limb, and across the back ob- 
liquely to the point of starting. Maw's mole- 
skin plaster, or some plaster equally strong, 
is to be preferred. The first strip is looped 
around the arm just below the axillary 
margin, and pinned, or stitched, with the 
loop sufficiently open to avoid strangulation. 
The arm is then drawn downward and back- 
ward until the clavicular portion of the 
pectoralis major is put sufficiently on the 
stretch to overcome the sterno-cleido-mas- 
toid, and thus draw the sternal fragment of 
the clavicle down to its place. The strip of 
plaster is then carried completely around the 
body, and pinned or stitched to itself on the 
back. The second strip is then applied, 
commencing on the front of the shoulder of 
the sound side, thence it is carried over the top of the shoulder, diagonally across 
the back, under the elbow, diagonally across the front of the chest, to the point 
of starting, where it is secured by pins or thread. A longitudinal slit is made in 
the plaster, to receive the point of the elbow. Before laying the plaster across 
the elbow, an assistant must press the elbow well forward and inward, and it 
must be held firmly in this position until the dressing is completed, It will be 
now seen that the arm has been converted into a lever, whose fulcrum is the 
loop of adhesive plaster at the lower margin of the axilla ; and upon this it is 
believed that in a great measure the efficiency of the apparatus depends. 




First strip of plaster. (Sayre.) 



Certainly it no longer depends upon the position of the elbow, which 
was at first carried back in order to render tense the clavicular fibres of 
the pectoralis major ; since, for the purpose of converting the humerus 
into a lever, the elbow is subsequently drawn forward, and the clavicular 
fibres of the great pectoral are again relaxed. If, therefore, the appa- 
ratus has any advantages over other modes of treatment, it is solely by 
its action upon the humerus as a lever ; but the fulcrum is too remote 
from the upper end of the humerus to act very efficiently. Great force 
has to be applied to secure this end, ox at least so much force that, if 
steadily maintained, it is pretty sure to cause excoriations of the arm 
where the fulcrum acts ; or, as more often happens, it will speedily loosen 
under the expansion and contraction of the chest in respiration, and 
thus cease to be efficient. Several cases of fractured clavicles, treated 



188 



FRACTURES OF THE CLAVICLE. 



in hospitals by this method, have come under my notice, some of which 
were dressed by Dr. Sayre himself, and the results have been no better 
than when my apparatus has been used, whilst they have in most cases 
caused much more discomfort. 



Fig. 85. 



Fig. 86. 





Second strip of plaster. (Sayre.) 



Dressing complete. (Sayre.) 



[Spohn, 1 of Corpus Christi, Tex., employs an apparatus which he calls the 
sub-clavicular or anterior chest splint. It is simply a piece of wood or sole 
leather made to fit the anterior surface of the chest just below the clavicular 
bones, two inches wide and long enough to reach the outer side of each arm ; 
the splint is well padded, and two pads are added to place under each end of 
the splint to fit into what he calls, the lateral triangular space of the chest; the 
pad should press well against the outer end of the clavicle, coracoid, and acro- 
mion processes, and sink in between the upper part of the arm and side of the 
chest, thus forcing the shoulder-joint outward. A figure-of-8 bandage is next 
applied and the dressing is complete. 

Trimmer, 2 of White Haven, Pa., states that Dr. Washburn first used an ap- 
paratus which he figures, having for its chief peculiarity a crutch in the axilla 
supported by a steel or iron ring ; this ring is sustained by straps, one passing 
over the opposite shoulder, and the other around the body. The advantage 
claimed for it is that it can be worn under the clothes and allows the moderate 
use of the arm. It has the great disadvantage of undue pressure in the axilla.] 

No apparatus, perhaps, has been so generally employed, among 
American surgeons, as that form of the sling introduced by Dr. George 
Fox into the Pennsylvania Hospital in 1828. 

Sargent says of it: " Fractures of the clavicles treated by this apparatus are 
daily dismissed from the Pennsylvania Hospital, and by surgeons in private 
practice, cured without perceptible deformity." Norris affirms that " the chief 
indications in the treatment of fracture of the clavicle are perfectly fulfilled by 
the use of this apparatus." H. H. Smith declares that Fox's apparatus accom- 



1 Med. and Surg. Reporter, 1887. 



Times and Reg., Oct. 19, 1889. 



FRACTURES OF THE CLAVICLE 



189 



plishes " perfect cures " in very many cases, and that it is " a very rare thing for 
a simple case to go out of the house (Pennsylvania Hospital) with any other 
deformity save that which time cures, viz., the deposition of the provisional 
callus." 

Fox's apparatus (Figs. 87 and 88) consists of a sling (1), a wedge-shaped 
axillary pad (3) made of muslin, also stuffed, and half the length of the humerus ; 
and of a stuffed collar (1). The axillary pad is placed, with its thickest end up- 
ward, in the axilla corresponding to the broken clavicle, and secured in place 
by tapes attached to its upper end, and made fast to the stuffed collar upon the 
opposite shoulder. The sling is, in like manner, suspended from the stuffed 
collar; or, the hand may be suspended over the front of the chest by a piece of 
muslin, looped under the wrist, and tied around the neck. No bandage is em- 
ployed to confine the elbow to the body, and no effort is therefore made to con- 
vert the arm into a lever, and thus force the shoulder out. 

It must be apparent to every practical surgeon that this apparatus 
could not answer "perfectly" all the indications of treatment, namely, 
to carry the shoulder up, out, and back, so that the clavicle would be 
made to unite without shortening or deformity. I must be permitted, 
however, to express a doubt whether it has made deformities of the clavi- 
cle "the exception, instead of the rule," with us. I have used this 



Fig. 87. 



Fig. 88. 




Fox's apparatus. 

dressing in ' the early years of my practice quite often, but my success 
has by no means been so flattering as has been the success of these gentle- 
men. I have seen others employ it, also, and with [much the same 
result. 

Of the treatment of fractured clavicles by the wire suture, said to have 
been suggested and practised by Langenbeck, 1 I have only to say that I 
trust, for the reputation of surgery, and the good of the patients, the 
practice of this distinguished surgeon will find few imitators. 

[The operation of wiring the fragments in fracture of the clavicle is by no 
means to be discarded when performed aseptically. It has given excellent 
results where union could not have been obtained without great deformity. Nor 
is it at all difficult of performance.] 



1 Langenbeck, Dawson, Med. Rec, May 20, 1882. 



190 FRACTURES OF THE CLAVICLE. 

Finally, while I deprecate incautious assumptions in regard to the 
capabilities of any form of dressing for broken collar-bones, a disposi- 
tion to which is manifested by more than one advocate of special plans, 
I am ready to declare my preference for an apparatus consisting essen- 
tially of a sling, axillary pad, and bandages to secure the arm to the 
chest. Among the considerable variety of dressings which I have used, 
this has seemed to me most simple in its construction, the most comfort- 
able to the patient, the least liable to derangement (if I except Yelpeau's 
dextrine bandage, and certain other forms of "immovable " dressings), 
and as capable as any other of answering the several indications pro- 
posed, while the patient is permitted to walk about. No apparatus is 
better able to answer the first indication, namely, to " carry the shoulder 
up," than the sling. Indeed, in nearly all the forms of dressing hitherto 
devised, the sling is employed for this purpose. The bandage carried 
beneath the elbow is, in effect, a sling. In a few instances, men of no 
practical experience have sought to substitute an upward pressure in the 
axilla for the sling ; but it is scarcely necessary to declare the absurdity 
of this practice, inasmuch as no patient will be found willing to submit 
to it beyond a few hours. 

It is proper to say, however, that some surgeons, whose opinions are entitled 
to respect, believe that it is quite as important to depress the sternal fragment 
as it is to elevate the acromial ; the outer end of the sternal fragment being 
lifted, more or less, by the action of the sterno-cleido-mastoid muscle. No doubt 
this is one of the difficulties with which we have to contend in our efforts to 
restore the two fragments to their original line of the axis of the bone. But then 
the elevation of the sternal fragment is only slight in any case. The rhomboid 
ligament quickly arrests its displacement in this direction, so that the marked 
projection of the outer end of this fragment is due rather to the depression of 
the outer fragments than to an elevation of the inner. Inclination of the head 
to the side of the fractured limb will allow the sternal fragment to fall; but it 
is impossible for the patient to maintain this position for any length of time. 
A compress laid over the sternal fragment, and held in place by adhesive straps 
or bandages, will be found totally inefficient. Dr. Moore has adopted a more 
ingenious and philosophical method, by calling into requisition the clavicular 
fibres of the pectoralis major to antagonize the sterno-cleido-mastoid. Indeed, 
this is one of the essential principles upon which he rests the superior claims of 
his dressing ; and I have myself observed that when, in the case of a recent 
fracture, the elbow is thrust behind the body, the outer end of the sternal frag- 
ment is depressed. Nevertheless, I have certain theoretical and practical objec- 
tions to the doctrine as taught so ingeniously by Moore. My theoretical objec- 
tion is that the clavicular fibres of the pectoralis major will soon, under the 
continual strain, become relaxed, and after a little time cease to accomplish 
what they did at first. This is a law in regard to the action of muscles put 
upon the strain, as every surgeon knows. It may be supposed that, if the pec- 
toral muscle is thus rendered less competent to depress the fragment, the sterno- 
cleido-mastoid will be rendered, also, less competent to elevate the fragment ; 
but this is not strictly true : the latter operates at right angles with the axis of 
the bone, and to great advantage, whilst the former acts very obliquely, and to 
a corresponding disadvantage. The practical objection which I have to offer is, 
that the dressings required to maintain this position are exceedingly liable to 
cause excoriations and to become disarranged, and that in fact this has hap- 
pened in all, or nearly all, of the cases which have been observed by me. More- 
over, whatever cause may be assigned for the failure, the results have been no 
better, so far as overlapping and deformity are concerned, than when my own 
dressings have been used. 



FRACTURES OF THE CLAVICLE. 191 

The second indication, namely, "to carry the shoulder back," is 
certainly more difficult of accomplishment than the first, and it is only 
imperfectly met by my own method, or by any other form of sling 
dressing. 

Desault taught that when the arm was lifted by the sling, or by any mode of 
pressure beneath the elbow perpendicularly, the shoulder was necessarily carried 
back. This is probably true, but its effect is not very marked. The ordinary 
figure-of-8, which might at first be supposed to be the most rational mode of 
effecting this purpose, has long since proved to be a failure. None of the con- 
trivances to hold the shoulders back by bands which traverse the axilla, made 
fast to back splints, have done any better. They all cause excoriations and 
soon become intolerable. 

After all, it must be said that the indication " to carry the shoulder 
back," except so far as it incidentally accomplishes the indication " to 
carry the shoulders out," and thus obviate the overlapping of the frag- 
ments, is relatively unimportant. It is seldom that the falling forward 
of the shoulders is very marked, or in itself a source of deformity ; but 
carrying the shoulder back does diminish or overcome the riding of the 
fragments, and in this view alone is it important, and for this reason 
surgery will be indebted to any one who devises a method by which this 
position of the shoulder can be maintained until the union of the frag- 
ments is consummated. 

The third indication is "to carry the shoulder out,'' by which means 
it is proposed to overcome, directly, the riding of the fragments. We 
have seen that this may be accomplished, indirectly, by carrying the 
shoulder back ; but, unfortunately, no means has yet been found by 
which this can be done and permanently maintained, while the patient 
is in the erect or sitting posture. The thick axillary pad, and all other 
devices by which it is proposed to act upon the humerus as a lever, and 
thus force the shoulder out, have totally failed or proved eminently mis- 
chievous. In short, I may say that this indication can, in my opinion, 
be effectually accomplished in only one way, and that is, by laying the 
patient upon his back on a flat, firm mattress, and thus pressing the 
base and inferior angle of the scapula strongly and steadily against the 
back. The requisite pressure upon the scapula cannot be maintained by 
any plan yet contrived while the patient is in the sitting or standing- 
posture, and especially when permitted to walk about. We shall be 
warranted therefore in attempting to accomplish this indication fully in 
only rare and exceptional cases. If a slight overlapping and deformity 
were to cause any appreciable diminution of the strength or usefulness 
of the arm, patients might properly enough be subjected to such restraints 
for a few weeks ; but experience has shown that such displacements do 
not, in any degree, maim the arm. Whether, in the case of women, in 
examples of unusual displacement, the danger of disfigurement would 
warrant a resort to this method, must be left to the judgment of the 
surgeon and the choice of the patient ; but in adopting what may be 
termed the " posture " treatment, it will be advisable also to employ the 
sling, pad, and bandages in the manner hereafter to be described. 

The mode of dressing a fractured clavicle which, while the patient is 



192 



FRACTURES OF THE CLAVICLE. 



at liberty to walk about, will secure the best results with the least suffer- 
ing and annoyance, is as follows : 

The arm hanging perpendicularly beside the body, a sling is placed 
under the elbow and forearm, and tied over the opposite shoulder. An 
axillary pad, composed of cotton batting inclosed in a cloth cover, is placed 
well up in the axilla, and the elbow is then secured firmly to the side of 
the body with several turns of a roller. 

Dr. Coates, 1 in the excellent paper already referred to, calls attention to the 
danger of making too much pressure upon the brachial artery and nerves, when 
the axillary pad is used, and the firm is, at the same time carried forward upon 
the body. In bringing the elbow forward, so as to lay the forearm across the 
body, the humerus is made to rotate inward, and the brachial artery and nerves 
are brought into -more direct apposition with the pad ; while in the position 
which I have recommended and practised hitherto, these nerves and vessels are 
removed in a great measure, but not entirely, from pressure. 

The pad should be no thicker than is necessary to fill completely the 
axillary space, its purpose being to steady the arm, and, in some slight 
degree, to counteract the action of those muscles which tend to displace 
the shoulder inward. It should be long enough in its antero-posterior 



Fig. 89. 



Fig. 90. 





The author's dressing for fractured clavicle. 



Four-tailed bandage. 



diameter to project distinctly in front and behind, otherwise it will not 
keep its place. In the adult it needs to be six or seven inches long. In 
the direction of the axis of the limb, its length should be less, perhaps 
four inches. Being now well pressed up into the axilla, and secured 
with a needle and thread to the upper edge of the roller which encircles 
the lower part of the arm and the body, it will keep its position and serve 



Coates, Amer. Journ. Med. Sci., vol. xviii. p. 62. 



FRACTURES OF THE CLAVICLE. 193 

some useful purpose. The sling may be made of cotton or flannel cloth, 
and suspended from the opposite shoulder by the aid of four tapes, a 
broad and thick pad of folded cloth being laid upon the shoulder to sup- 
port the knots. A considerable experience has satisfied me that the 
stuifed collar, used in the Fox dressing, possesses no advantage as a 
means of suspension. The leather sling, also, in use in some hospitals, 
is liable to the objection that it cannot be stitched to the roller, which 
encircles the body and lower part of the arm in the manner I shall here- 
after describe. The roller should be made to encircle the lower fourth of 
the arm, and a few turns should pass beneath the forearm as far forward 
as the hand, in this manner securely fixing the elbow and forearm against 
the side and front of the body. 

If thought necessary, the hand may be supported by a loop of bandage passed 
under the wrist and tied over the neck. In order* that this dressing may retain 
its place and serve its purpose most effectually, its several parts should be 
stitched together thoroughly wherever the dressings cross or approach each 
other. In no other way can anything like permanency be insured in a portion 
of the body so movable as the shoulder and chest; but even with this precaution, 
daily attention and occasional readjustment are generally required. 

[A simple and very efficient apparatus, especially for children, is illustrated 
by Fig. 90. 1 It consists of a piece of strong calico, fourteen inches wide, and 
sufficiently long to go around the body one and a half times: cut a hole in its 
centre, about four inches from the margin, for the point of the elbow ; split up 
the ends of the bandage in the same line as the hole, that is, four inches from 
the border to within about six inches of the hole. This makes a four-tailed 
bandage with tails of unequal breadth, one four inches broad, the other ten. 
Now place a wedge-shaped pad in the axilla, if thought necessary; lay the 
patient flat on his back to enable the fragments to fall into position ; lay the 
arm to the side and flex the forearm on the chest ; apply the bandage in such 
manner that the point of the elbow shall stick into the hole and the broad tail 
of the bandage enclosing the humerus be brought across the chest and fastened 
to the opposite side of the body, thus binding the arm to the side ; the narrow 
tail, which will be below the elbow, is now crossed over the broad tail and tied 
over the top of the opposite shoulder.] 

Treatment of Incomplete Fractures of the Clavicle. — In case of 
partial fracture of the clavicle, accompanied with a persistent bend in the 
line of the axis of the bone, it is proper to attempt the replacement of 
the fragments by direct pressure. The ends of the bone being fixed, we 
cannot, as in the case of a partial fracture of other long bones, employ 
leverage ; and with direct pressure alone, applied in a degree which 
might be regarded as incurring no danger of causing a complete frac- 
ture or of a dislocation, our chances of success are very small. I cannot 
say that I have ever succeeded in accomplishing anything in this way, 
although I have often made the attempt, and would always advise others 
to do the same. A failure, however, to restore completely the line of 
the axis of the bone is not, I imagine, a matter of great consequence, 
since, as has already been fully explained when speakiug of partial 
fractures in general, the natural form will be in most, if not in all cases, 
completely restored after the lapse of a few months or years. This 
observation applies especially to partial fractures occurring in childhood 

1 Pick, Fractures and Dislocations. 
13 



194 FRACTURES OF THE SCAPULA. 

and infancy. I have no experience as to what is the result of a similar 
deformity left after a partial fracture in the adult. 

As to the method of dressing these fractures, it need not differ from 
that recommended for complete fractures ; but in a majority of these 
cases I have thought it sufficient to place the arm in a sling, with a 
bandage around the elbow and body to keep the arm at rest ; or I have 
directed the mother to make the sleeve fast to the front of the dress with 
tapes ; or the hand and arm of the child may be withdrawn from the 
sleeve and placed across the body inside the dress, and secured in this 
position by a belt around the waist. In this case, of course, the dress 
must remain upon the child until the cure is completed. The axillary 
pad can seldom, if ever, serve any useful purpose. Union occurs with 
great rapidity, sometimes a»j early as the seventh or tenth day ; but the 
arm ought to be kept quiet, as a matter of safety, two or three weeks. 



CHAPTEK XX. 

FRACTURES OF THE SCAPULA. 

Fractures of the scapula may be divided into those which occur 
through the body, the neck, the acromion process, and the coracoid. 

§ 1. Fractures of the Body of the Scapula. 

Under this title I propose to consider not only fractures of the " body," 
properly speaking, but also fractures of the angles and of the spine. 

Causes. — The scapula is usually broken by the fall of some heavy body 
directly upon the bone, or by some severe crushing accident, by the kick 
of a horse, by a fall upon the back ; in short, by direct causes alone, and 
by such causes as operate with great violence. 

I have recorded six cases which were under my treatment; and I have seen 
a few other examples of fractures of the body of the scapula not caused by 
firearms. There are two cabinet specimens of fracture of the body of the scapula 
below the spine in the Pennsylvania Medical College, and two involving the 
spine. Dr. Mutter had in his collection a fracture of the posterior angle, and 
Dr. March had a specimen of fracture of the body. Among 2358 fractures 
reported from Hotel Dieu during a period of twelve years, only four examples 
of fracture of the scapula are recorded; and, at Middlesex Hospital, Lonsdale 
has noticed, among 1901 fractures, only eight of the body of the scapula. 

The infrequency of this fracture is no doubt due in a great measure to 
the elasticity of the ribs, to the mobility of the scapula, and to the soft- 
ness of the muscular cushion upon which it reposes. 

[McKee, 1 of Sacramento, Cal., reports two cases of fracture of the body of the 
scapula, one being complicated with fracture of a rib on either side of the clavicle 

1 Sacramento Mecl. Times, May, 1887. 



FRACTURES OF THE BODY OF THE SCAPULA. 



195 



at the junction of its inner and middle thirds, 
presses with broad adhesive bands.] 



The treatment consisted of com- 



Symptoms. — Since this bone is seldom broken except by great force 
directly applied, the usual signs of fracture are likely to be concealed by 
the speedy occurrence of swelling. It is for this reason that it becomes 
necessary, generally, that the examination should be made with great 
care before we can safely determine upon the diagnosis. When, how- 
ever, the line of the fracture has traversed the spine, and any considerabe 
displacement has occurred, one 
may recognize the fracture easily 
by merely carrying the finger 
along the crest. If the fracture 
has occurred through the body, 
below or above the spine, or 
through either of the angles, the 
displacement may not be so easily 
recognized. The surgeon ought 
then to trace carefully with his 
finger the outlines of the scapula ; 
and this he will be able to do 
more satisfactorily if he places the 
scapula in such positions as ele- 
vate its margins and render them 
more prominent. In examining 
the posterior angle, the hand of 
the injured limb may be placed 
upon the opposite shoulder, the 
forearm being carried across the 
front of the chest ; but in search- 
ing for a fracture below the spine, 
the forearm ought to be laid across 
the back. Crepitus, which is not 
always present owing to the fact 
that the fragments overlap com- 
pletely, or because they have been 
widely separated by the action of 
the muscles, may generally be detected by placing the palm of the hand 
upon some portion of the scapula, so as to steady the fragment upon 
which it rests, while the arm is moved backward and forward, and in 
various other directions, until their broken surfaces are brought into 
contact. Some degree of embarrassment in the motions of the shoulder 
and arm must always result from this fracture ; sometimes this embarrass- 
ment is very great, but it ought not to be considered ever as diagnostic 
of a fracture, since it may be produced equally by a severe contusion ; 
and even when it is accompanied with a fracture, it is due rather to the 
contusion than to the fracture. 

Pathology, Seat, Direction, etc.— Of incomplete fractures of the 
scapula, I have seen one example. Complete fractures occur most often 
below the spine, and they are generally oblique or transverse, sometimes 




Fracture of the posterior angle of scapula, 
with fissure. Mutter' s collection, Specimen C, 
:N T o. 187. 



196 FRACTURES OF THE SCAPULA. 

nearly longitudinal. Fractures involving the spine are noticed occa- 
sionally ; but I am not aware that any one has ever seen a specimen of 
a fracture of the spine alone, although many surgeons have spoken of 
them. One example of a fracture of the posterior angle is in the cabinet 
of Mutter, of Philadelphia. Occasionally the bone is broken into more 
than two fragments. As a result of the fracture there is usually more or 
less displacement ; generally, if the fracture is below the spine and trans- 
verse, and especially if its direction is oblique from before backward and 
downward, the inferior fragment is displaced forward, or forward and 
upward, by the action of the serratus major anticus, or of the teres major, 
whilst the superior fragment is inclined to fall backward, and sometimes 
it is carried upward and backward, following the action of the rhom- 
boideus major. In cases of comminuted fractures, and occasionally in 
simple fractures, the direction of the displacement is reversed, or alto- 
gether changed, so that the lower fragment, instead of being in front, is 
behind the upper fragment ; and instead of overlapping, the two frag- 
ments are more or less drawn asunder. These are deviations which are 
not easily explained, but which depend, perhaps, rather upon the direction 
of the blow than upon the action of the muscles. In a few cases there 
is no displacement in any direction, although the crepitus and mobility 
sufficiently demonstrate the existence of a fracture. 

Prognosis. — If displacement actually has taken place, it will be found 
very difficult to hold the fragments in apposition until a cure is com- 
pleted ; so that they are pretty certain to unite with a degree of over- 
lapping, or other irregularity. 

Lonsdale, Lizars, Chelius, Nelaton, Gibson, Malgaigne, and others have 
spoken of the difficulty or impossibility generally of keeping these fragments in 
place. Nelaton and Malgaigne, indeed, confess that they have never succeeded; 
Gibson declares that it is scarcely possible ; while Chelius affirms that if the 
fracture is near the angle, the cure is always effected with some deformity. 

It is not probable that the patient will ever suffer any serious incon- 
venience from the irregular union of the fragments, since the perfection 
of its function depends less upon any given form or size than in the case 
of almost any other large bone ; and if the free use of the arm is not 
recovered for some time, or if a permanent stiffness results, these should 
be regarded as due to the injury which those muscles have suffered which 
envelop the scapula, or to some injury of ligaments and muscles which 
surround the shoulder-joint. In some few examples upon record, the 
bone has been so comminuted, and the soft parts adjacent so much 
injured, that suppuration and necrosis have ensued. 

In a case of gunshot fracture of the scapula, resulting in necrosis, I had. occa- 
sion to remove the entire scapula. 1 The case is briefly as follows : Private W. 
M. was wounded by grape-shot, which fractured both the scapula and head of 
the humerus. Six days later the head and a portion of the shaft of the humerus 
were removed. At a later period necrosis attacked the scapula, and I removed 

i Surgical History of the "War of the Rebellion, vol. ii., Washington, 1876, pp. 492, 494. 
498, 499, 500. Proceedings of N. Y. Patholog. Soc., 1866, in Med. and Surg. Keporter, vol. 
xiv! p. 372. 



FRACTURES OF THE BODY OF THE SCAPULA. 197 

the entire scapula, including the acromion and coracoid processes. He recovered 
very good use of the limb, and was able to contract effectively the biceps and 
coraco-brachialis, although their upper points of attachment were only cica- 
tricial tissue. Dr. Otis, compiler of the Surgical History of the War of the 
Rebellion, who has gathered a complete account of this case, remarks that " it 
affords perhaps a solitary example of a successful extirpation, for the results of 
shot injury, of the scapula, with preservation of the upper extremity.'' 

Treatment. — In the treatment of this fracture, the first object with all 
surgeons has been to restore the fragments to place, and this they have 
chiefly sought to accomplish by position; after which they have en- 
deavored to immobilize the fragments by bandages, etc. In seeking to 
accomplish the first indication, they have placed the shoulder and arm 
in a great variety of postures. Nearly all seem to have regarded it as of 
some importance that the shoulder should be elevated, so as to relax the 
muscles attached to the upper and back part of the scapula, and thus 
permit the upper fragment to fall downward and forward. 

In the treatment of no other fracture, perhaps, have surgeons differed 
more widely as to the indications than in this ; some recommend the 
elbow to be carried from the body, and some that it shall be made to 
approach the body ; one directs that the elbow shall fall perpendicularly 
beside the chest, a second prefers that it shall be carried a little back, 
and a third that it shall be brought well forward. In one thing alone 
have they nearly all agreed, namely, that the elbow shall be lifted ; and 
generally also it has been recommended that the arm, forearm, and body 
shall be confined by sufficient bandages to insure quietude. It might be 
proper to conclude, therefore, that the sling and bandage constitute all 
of the apparatus which is necessary or useful ; and that it is relatively 
unimportant whether the elbow is near or remote from the body, or 
whether it is in front of, or behind, or beside the chest. Such, indeed, 
is the conclusion to which I have myself arrived ; yet if, in relation to 
the position of the elbow, a choice were to be expressed, I would give the 
preference to that in which the arm is laid vertically beside the body, or, 
perhaps, with the elbow a little inclined backward, so as to relax as com- 
pletely as possible the teres major. It is quite probable, however, that 
no single position will be found of universal application ; and perhaps it 
would be more safe to advise the surgeon in any given case first to reduce 
the fragments as completely as possible by manipulation, and then to 
place the arm in such a position as, upon careful experiment in this par- 
ticular instance, he shall find enables him best to retain them in place. 

If, however, the fracture is such as to have separated the inferior 
angle from the body, it will be well to follow the advice of Boyer and 
of others, and to place a compress in front of the inferior angle, to resist 
the greater tendency to displacement in this direction. This compress 
will more effectually accomplish this indication if the roller with which 
it is secured to the body, and with which w T e seek to immobilize the 
scapula and chest, is turned from before backward, or in a direction of 
antagonism to the action of the muscles which produce the displacement. 

Desault, with Chelius and Bransby Cooper, has recommended also, in the case 
of a fracture through the angle, that the forearm should be acutely flexed upon 
the arm, and that the hand should be placed in front of the chest, upon the 



198 



FRACTURES OF THE SCAPULA, 



sound shoulder, a position which is always irksome, and sometimes insupport- 
able, and which does not offer in any case sufficient advantages to render it 
worthy of a trial. 



§ 2. Fractures of the Neck of the Scapula. 

If by the " neck " of the scapula surgeons mean that slightly con- 
stricted portion of this bone which is situated at the base of the glenoid 
cavity, the u anatomical" neck, its fracture is certainly very rare. 

Indeed, the existence of this fracture, uncomplicated with a comminuted frac- 
ture of the glenoid cavity, is denied by Sir Astley Cooper, South, Erichsen, and 
others. Mr. South says there is no such specimen in any of the museums in 
London ; and I have not been able to find one in any of the American cabinets. 
Dr. Valentine Mott had never seen a specimen, and in the natural condition of 
the bone he regards its occurrence as impossible. Such, I confess, also, is my 
own conviction. 

If, however, it is intended, in speaking of fractures of the neck of the 
scapula, to refer only to fractures extending through the semilunar notch, 



Fig. 92. 



Fig. 93. 




Comminuted fracture of the 
glenoid cavity. 




Fracture of the neck of the scapula: 
according to Sir Astley Cooper. 



behind the root of the coracoid process, " surgical " neck, then its exist- 
ence is certain ; yet the fracture is not common. 

Duverney has reported one example, the existence of which he established by 
a dissection. The coracoid process was broken at the same time, but the frac- 
ture through the surgical neck was distinct from this ; and Sir Astley has recorded 
three examples in which the diagnosis was very clearly made out, yet not actually 
proved by an autopsy. 

There is one specimen in the museum of Guy's Hospital ; another, in which 
repair has taken place, in the museum of the Royal College of Surgeons. 1 Per- 



1 Holmes's Surgery, vol. ii. p. 776, Amer. ed- 1870. 



FKACTURES OF THE ACROMION PROCESS. 199 

haps some of the cases, diagnosticated during the life of the patient as fractures 
of the neck of the scapula, were fractures of the lower or anterior lip of the glenoid 
cavity ; but I have never found such a specimen in any collection of bones which 
I have yet examined, and it must be admitted to be exceedingly rare. 

[Heminway, of Kalamazoo, Michigan, reports a case of injury to the shoulder 
in the person of a physician which he seems to have correctly diagnosticated as 
fracture of the neck of the scapula. It was first taken to be a dislocation of the 
shoulder, but the restoration to place was like that of a fracture of the neck of 
the scapula, and was followed by crepitus. 1 

Parker, 2 of Liverpool, reports three cases of this fracture, all the result of severe 
accidents. There was paralysis of the muscles, with the more marked signs of 
dislocation of the humerus. Eeduction was followed by the return of deformity. 
The position which most completely restored the bone, and was comfortable, 
required that the arm should be slung with the hand lying on the top of the 
right shoulder, and retained by a triangular bandage.] 

Symptoms. — Sir Astley Cooper justly remarks that "the degree of 
deformity produced by a fracture of the surgical neck of the scapula 
depends upon the extent of laceration of a ligament which passes from 
the under part of the spine of the scapula to the glenoid cavity. If this 
be torn" (and to this we ought to add the ligaments passing from the 
coracoid process to the clavicle and acromion process — coraco-clavicular 
and coraco- acromial), u the glenoid cavity and the head of the os humeri 
fall deeply into the axilla, but the diplacement is much less- if this 
remains whole." The usual signs are, a depression under the acromion 
process, the same as in dislocation of the head of the humerus downward, 
but not so deep ; the head of the humerus felt, perhaps, in the axilla : 
crepitus, and the immediate recurrence of the displacement whenever, 
after the reduction has been fairly accomplished, the arm is left unsup- 
ported. The crepitus is best discovered by resting one hand upon the 
top of the shoulder in such a manner as that a finger shall touch the 
point of the process, while the arm is rotated and moved up and down 
by the opposite hand. It may also be easily ascertained that the cora- 
coid process moves with the humerus instead of the scapula. Occasion- 
ally the accident is accompanied with paralysis of the arm, from pressure 
upon the axillary nerves ; and a rupture of the axillary artery is also 
mentioned by Dugas. 3 

Treatment. — The indications of treatment are three, namely, to carry 
the head of the humerus, with the glenoid cavity, etc., up, to carry it out, 
and to confine the body of the scapula. The first is accomplished by a 
sling, the second by 'a pad in the axilla, and the third by a broad roller 
carried repeatedly around the arm and chest and across the shoulder. In 
short, the treatment is essentially the same as that which I have recom- 
mended for a broken clavicle. 



§ 3. Fractures of the Acromion Process. 

There is some reason to believe, I think, that a true fracture of the 
acromion process is much more rare than surgeons have supposed, and 

1 Journ. Amer. Med. Assoc, 1887. 2 Brit. Med. Journ., Aug. 22, 1885. 

3 Remarks on Frac. of Scapula, by L. A. Dugas, Georgia. Amer. Journ. Med. Sci., Jan. 
1858. 



200 FKACTTJRES OF THE SCAPULA. 

that in a considerable number of the cases reported there was merely a 
separation of the epiphysis ; the bony union having never been com- 
pleted. If such fractures or separations occurred only in children, very 
little doubt might remain as to the general character of the accident ; 
but the specimens which I have found in the museums, and the cases 
reported in the books, have been mostly from adults. It is more diffi- 
cult, therefore, to suppose these to be examples of separation of epiphy- 
ses, but I am inclined to think that in a majority of instances such has 
been the fact. It is very probable, also, that in the case of many of the 
specimens found in the museums, called fractures, the histories of which 
are unknown, they were united originally by cartilage, and that in the 
process of boiling, or of maceration, the disjunction has been completed. 
The narrow crest of elevated bone which frequently surrounds the pro- 
cess at the point of separation, and which Malgaigne may have mistaken 
for callus, is found upon very many examples of undoubted epiphyseal 
separations which I have examined; and this circumstance, no doubt, 
has tended to strengthen the suspicion that these were cases of fracture. 

The opinion is confirmed by the remark of Mr. Fergusson that a fracture of 
this process is an accident " of rare occurrence." " I have dissected," he adds, 
"a number of examples of apparent fracture of the end of this process; but in 
such instances it is doubtful if the movable portion had ever been fixed to the 
rest of the bone." Dr. Jackson says there are four specimens in the museum of 
the Massachusetts Medical College, and in the museum of the Boston Society for 
Medical Improvement, which might easily be mistaken for fractures, but which 
only illustrate to how late a period the bony union is sometimes delayed. In one 
specimen the patient could not have been less than forty years of age; "the 
acromial process of each scapula was fully formed, but having no bony union 
whatever with the bone itself. The union was ligamentous, but strong and 
close." 

[On the contrary, Lane, 1 of London, states that in a careful examination of the 
bones of 325 bodies in the dissection he has found that a considerable proportion 
presented fractures of the acromion, and he concludes that this portion of the 
scapula is broken more frequently than any other bone in the body. He attrib- 
utes the discrepancy in the estimate of the frequency of this fracture by those 
who publish statistics to the fact that fractures of the acromion are generally over- 
looked. He states that in many instances of so-called contusion of the shoulder 
of the living subject he has been able to satisfy himself of the presence of an 
ununited fracture of the acromion.] 

To the same class belong several specimens in my own collection; in March's 
• collection in Albany ; two specimens in the Mutter, and one in the Jefferson 
Medical College museums. In my own specimens, as well as most of the speci- 
mens which I have examined, the ends of the fragments were closed with a 
compact bony tissue. 

The mode of development of the scapula will explain these cases. The 
scapula is formed from seven centres ; namely, one for the body, one for 
its posterior border, one for its inferior border, two for the acromion 
process, and two for the coracoid. Ossification of the body exists to a 
certain extent at or near the period of birth. It commences in one of 
the centres of the coracoid process, about one year after birth, and unites 
to the body at about the fifteenth year. All the other centres remain 
cartilaginous until from the fifteenth to the seventeenth year, when 

i Brit. Med. Journ., May 19, 1888. 



FRACTURES OF THE ACROMION PROCESS. 



201 



ossification commences, and is completed by a common union among all 
parts, usually between the twenty-second and twenty-fifth years. There 
is no doubt, however, that a fracture of this process does occasionally 
take place. 

Fig. 94. 




Scapula, with epiphysis. (From Gray.) 



Examples of fracture of the acromion process have been reported by Duverney, 
Bichat, Avrard, A. Cooper, Desault, Sanson, Nelaton, Malgaigne, West, Brainard, 
Stephen Smith, and others. I have myself seen five cases. In the case seen by 
Cooper it entered the articulation of the clavicle, and produced at the same 
moment a dislocation. Malgaigne says it occurs generally further up, and pos- 
terior to the attachments of the clavicle, " near the junction of the diaphysis 
with the epiphysis," and that the fracture is in most cases transverse and ver- 
tical ; but Nelaton saw a case in which the fracture was oblique. In the case 
reported by C. West, of Hagarstown, Md., the fracture was through the base of 
the process. In two of the examples seen by me the fracture was in front of the 
clavicle; in the third, occasioned by the fall of a barrel of flour upon the 
shoulder, the fracture occurred at the acromio-clavicular articulation, and was 
accompanied with an upward dislocation of the outer end of the clavicle ; in the 
fourth, the fracture occurred at the same point, but there was neither displace- 
ment of the clavicle nor of the process, the fracture being only recognized by 
crepitus and motion. The fifth was brought to my notice by Dr. Sabine, sur- 
geon to Bellevue Hospital. The patient had been struck by a policeman's club. 
There was distinct crepitus, the fracture being posterior to the acromio-clavicular 
junction, but there was no displacement of the fragments or of the clavicle. 
Some of the fractures were confirmed by dissection, and in the case mentioned 
by Stephen Smith, an autopsy, made three weeks after the accident, showed a 



202 FRACTURES OF THE SCAPULA. 

fracture in front of the clavicle without displacement, the periosteum covering 
its upper surface not being torn ; the fragment could be turned back as upon a 
hinge. 

[This fracture was caused by a blast ; a fragment of rock being driven upward 
struck the acromion on the under surface.] 

Prognosis when the Fracture is in front of the Clavicle. — The pro- 
cess generally unites with a slight downward displacement. In such 
cases the motions of the arm are not in consequence much, if at all, im- 
paired ; unless, indeed, it is so much depressed as to interfere w T ith the 
upward movements of the arm. 

Sir Astley Cooper says that a true bony union is rare in these fractures, and 
that there generally results a false joint, the fragments uniting by a fibrous 
tissue; but sometimes the surfaces, instead of uniting either by bone or ligament, 
become polished and even eburnated. Malgaigne has noticed, also, a specimen 
contained in the Dupuytren museum, a hypertrophy of the lower fragment, this 
portion having a diameter nearly twice as great as that of the portion from 
which it was detached. ' 

Prognosis when the Fracture is through the Articulation of the 
Clavicle. — Where neither the fragments nor the clavicle are displaced, 
the prognosis ought to be favorable ; but in case the clavicle is dislocated, 
there will be encountered the same difficulties as in the case of simple 
acromial dislocation of the clavicle, or even more serious difficulty, and 
I do not see how it can be expected that a perfect reduction should be 
maintained. 

Prognosis when the Fracture is Posterior to the Articulation of the 
Clavicle. — In these cases, if there is little or no displacement, the prog- 
nosis is favorable ; but if the fragments are displaced, a perfect adj ust- 
ment may be difficult. 

Symptoms. — Where no displacement exists, the diagnosis must always 
be difficult, if not impossible. In such a case we could only be instructed 
by the manner in which the injury had been received, by the contusion, 
and by the presence of mobility or crepitus. In examples attended with 
displacement, if no swelling is present, the finger, carried along the spine 
of the scapula to its extremity, will easily detect the fracture by the 
abrupt termination or elevation of the process, or by the presence of a 
fissure, or a depression ; but as to the other symptoms, they must depend 
very much upon the point at which the fracture has taken place. If in 
front of the acromio-clavicular articulation, the position of the arm in its 
relations to the body will not be changed ; but if the fracture is through 
the articulation, and a dislocation of the clavicle results, or if it is behind 
the acromio-clavicular articulation, the arm, having in either case lost 
the support of the clavicle, will be inclined to assume the same position 
that it does in a fracture of the clavicle; that is, the shoulder will be 
disposed to fall downward, inward, and forward. 

Treatment. — If the fracture has taken place in front of the acromio- 
clavicular articulation, no doubt the most rational plan of treatment, if 
one aims at the accomplishment of a perfect bony union, is placing the 
patient in bed, upon his back, and carrying the arm out from the body 
nearly to a right angle ; since by this method the fragment is not only 
lifted, but the deltoid muscle is relaxed, and, consequently, the fragment 



FRACTURES OF THE CORACOID PROCESS. 203 

is no longer forcibly drawn away from the spine of the scapula. If, 
therefore, the patient will submit to this treatment for a sufficient length 
of time, the union must be accomplished with the least possible amount 
of displacement. But in the case of a fracture of the acromion process 
at the point indicated, only a few fibres of the deltoid muscle are attached 
to the fragment which has been broken off, and, consequently, even in 
case no union took place, the muscular power of the arm could not be 
appreciably impaired. Nor would a slight falling or depression of the 
fragment cause any embarrassment to the motions of the shoulder-joint. 
For these reasons it is scarcely worth while to do anything more, in a 
great majority of cases, than to place in the axilla a pretty heavy wedge- 
shaped pad, with its apex upward, and then secure the arm to the side 
with a sling and roller, the same as in the case of a fracture of the 
clavicle. If, however, the fracture has taken place at or behind the 
junction of the clavicle with the process, the indications of treatment will 
be, in all respects, the same as in the case of a fracture of the clavicle. 

[Haldeman, 1 of Zanesville, O., applied also a pliable compress immediately 
over the fracture in order to preserve the natural roundness and fulness of the 
shoulder. He is of the opinion that it fulfilled its purpose admirably.] 



§ 4. Fractures of the Coracoid Process. 

The existence of this form of fracture, established by at least nine or 
ten dissections, can no longer be denied ; yet it is often accompanied 
with serious complications, and such as have sometimes proved fatal. In 
the only two cases, however, in which I have had reason to believe that 
I had to deal with a fracture of this kind, the symptoms and termination 
were less grave, although they were both complicated with an upward 
dislocation of the outer end of the clavicle. 

[Mr. Arbuthnot Lane 2 has published an interesting paper on " Mode of Fix- 
ation of the Scapula : suggested by a study of the movements of that bone in 
extreme flexion of the shoulder-joint, and its bearing upon the fracture of the 
coracoid process." He contends that fixation of the scapula occurs only when 
that bone is in a state of extreme flexion. In that condition the coracoid pro- 
cess presses firmly upon the under surface of the clavicle, and effectually pre- 
vents further flexion. If violence continues to be applied in this situation the 
coracoid process may be broken. This, he thinks, explains the cause of that 
fracture when a person falls forward with the arms stretched directly forward, 
and being completely flexed at the shoulder.] 

A gentleman residing in the country was struck by a board which fell edge- 
wise upon his shoulder. An apparatus was applied to retain the clavicle in its 
place, but after three months, when he called upon me, it still remained dis- 
placed as at first. On laying off the dressing, I discovered that the coracoid 
process was detached, obeying constantly the movements of the head of the 
humerus, but being not at all subject to the movements of the scapula. The 
functions of the arm were not impaired. A girl fell upon her left shoulder, and 
sustained a complete luxation of the acromial end of the clavicle, upward and 
outward. Upon careful examination, a fracture of the coracoid process was 
indicated by both mobility and crepitus. 

1 Cin Lancet and Clinic, 1885. 

2 Brit. Med Journ., Mav 19, 1888. 




204 FRACTURES OF THE SCAPULA. 

Bransby Cooper relates a case of fracture through the base, which after eight 
weeks, when the patient died, was found to be united by a ligament. The acro- 
mion process was broken at the same time, 
F 95 and had united in the same manner. The 

head of the humerus was also broken 
partly united. 1 One example occurred 
in the practice of Dr. Arnott, London, 
in consequence of which the patient 
died, when a dissection disclosed the true 
nature of the accident. 2 South has re- 
ported a case. The humerus was partially 
dislocated forward, the clavicle, acromion 
process, and the olecranon were broken as 
well as the coracoid process ; after the 
patient died, on the fourth day, the exist- 
ence of these fractures was ascertained by 
dissection. 3 Holmes has reported a case. 4 
There is in the museum of University 
College a preparation showing a fracture 
\ * /f at the base of the process, the line of frac- 

\y/ ture extending across the glenoid cavity. 5 

Fracture of the coracoid process. Duverney , Boy er and Malgaigne have re- 

ported tour additional examples, con- 
firmed by dissections. 6 
Neill, of Philadelphia, has a specimen of separation of this process at about 
one inch from its extremity ; the scapula is large, and evidently belongs to an 
adult, and the fact that the acromion process is not yet united by bone renders 
it probable that this is an epiphyseal separation. Gibson, of Richmond, Va., 
has a specimen, from an adult, which has been broken obliquely near the end, 
but which is now united by a ligamentous or fibrous tissue of one line and a half 
in length. The fragment is displaced a little forward as well as downward. 
Mussey, of Cincinnati, possessed a very remarkable and conclusive example of 
this fracture. The humerus is dislocated forward, the head and neck being 
firmly united to the neck and venter of the scapula, while at the same time the 
coracoid process is broken and displaced. 

Little, of this city, had an example of this fracture. The arm, forearm, and 
hand were completely paralyzed. The coracoid process seemed to be displaced 
inward, or toward the median line of the body ; but when the humerus was 
forcibly rotated outward, the coracoid resumed its place, and if now pressure 
was made upon its extremity, it became again suddenly displaced, with a sub- 
dued, grating sensation. 

E. Hulme believed that he had met with the fracture, caused by muscular 
action, in the person of a man who, in falling, was caught by his arm in such a 
way that it was drawn forcibly from the body. 7 

Bennett, of Dublin, met with a case of separation of the coracoid epiphysis in 
the person of a boy set. six years. He had been knocked down by a tram-car 
and so severely injured that amputation of the arm at the shoulder was required; 
he died of tetanus, and the autopsy showed separation of the coracoid. It was 
detached at its base, the line of separation passing through the proximal side of 
the cartilage, and at the upper and back part taking off a scale of bone from the 
supra-spinous fossa. 8 

[Johnson, 9 of Baltimore, has collected twenty-seven cases of fracture of the 
coracoid. In one case the fracture was caused by muscular action. The accom- 
panying injuries are numerous, as dislocation and fracture of the humerus, dis- 

1 B. Cooper, edition of Sir Astley on Frac. and Disloc, Amer. ed., p. 380. 

2 Arnott, Fergusson's Surg , p. 231. 

3 South, Lond. Med.-Chir. Rev., 1840, vol. xxxii., new series, p. 41. 
* Holmes, Med.-Chir. Trans., vol. xli. p. 447. 

5 Erichsen, Surgery, p 207. 6 Malgaigne, op. cit , p. 512. 

7 Hulme, Lancet, vol. ii. p. 737, 1873. 

8 Dublin Journ. Med. Sci., 18S8'. 9 Med. News, Nov. 21, 1885. 



FKACTURES OF THE HUMERUS. 205 

location of the outer end of clavicle, fracture of the base of the skull, dislocation 
of humerus, paralysis of arm, etc.] 

It has been generally stated that when this process is broken off, it 
will be carried downward by the united action of the pectoralis minor, 
the short head of the biceps, and the coraco-brachialis muscles ; but this 
will depend upon whether the coraco-clavicular ligaments are ruptured 
also ; a circumstance which is not very likely to occur, at least to any 
great extent ; and in fact not one of the well-attested examples of this 
fracture has ever been accompanied with any considerable displacement 
in this direction. 

Treatment. — In a case of simple fracture of the process, unattended 
with any other lesions, it has been recommended to place the arm in a 
sling, with the elbow advanced as much as possible upon the front of the 
chest, as by this position we relax somewhat all of the three muscles 
having attachments to this process, and then to confine the scapula by a 
few turns of a roller. It is not probable, however, that by these meas- 
ures we would accomplish enough to justify their continuance if they 
were found to be painful, or even exceedingly irksome. Patients under 
my observation have generally complained very much of the pain and 
discomfort attending this position of extreme flexion of the arm and fore- 
arm, first employed by Velpeau for fractures of the clavicle. Moreover, 
I do not think the fragments are generally displaced ; and if they were, 
and the final union were to be accomplished solely by ligament, I think 
the usefulness of the arm would not be at all impaired. Such, at least, 
has been my experience in the two cases above recorded, and in both of 
which no bony union occurred. In Dr. Little's case rotation of the 
humerus outward seemed to effect a reduction, but upon what principle 
precisely this position acted to effect the reduction I am not prepared to 
say ; perhaps by drawing upon the coraco-brachialis and short head of 
the biceps — nor am I prepared to say that it would accomplish the same 
result in any other case, yet it may deserve a trial. In the graver forms 
of the accident, where other bones about the shoulder are broken or dis- 
located, or the limb has suffered other severe injuries, which, as we have 
seen, constitute the larger proportion of the whole number, the treatment 
must generally have little or no regard to this particular injury. 



CHAPTEE XXI. 



FRACTURES OF THE HUMERUS. 

Unfortunately, surgical writers have not been agreed in the use and 
application of the terms "head," "neck," "anatomical neck," and "sur- 
gical neck" of the humerus; and, as a consequence, the meaning is 
often obscure, and their teachings are sometimes contradictory and 
absurd. It is necessary, therefore, that we should define them more 



206 FRACTURES OF THE HUMERUS. 

precisely. The "head" of the humerus is that smooth, elliptical sur- 
face, covered by cartilage and synovial membrane, which articulates with, 
and is received into, the glenoid cavity of the scapula. The "anatomi- 
cal" neck is the narrow line immediately encircling the head, and which 
receives the insertion of the capsular ligament. The " surgical" neck is 
that portion which commences at the lower margin of the tubercles, or at 
the point of junction between the epiphysis and the diaphysis, and which 
terminates at the insertion of the pectoralis major and latissimus dorsi. 
The " neck " is all of that portion included between the head and the 
insertions of the pectoralis major and latissimus dorsi ; comprising not 
only the anatomical and surgical necks, but also the tubercles ; which 
latter occupy the triangular space between these two. 

Of 203 fractures of the humerus examined and recorded by me, 51 occurred 
through the upper third, 43 through the middle third, and 103 through the lower 
third. Of the fractures belonging to the upper third, 6 were supposed to be 
epiphyseal separations, one was probably a fracture at or near the anatomical 
neck, with impaction and splitting of the tubercles, one was a fracture of the 
greater tubercle alone, and 44 were fractures at or near the surgical neck ; some 
of them probably involving the shaft below the neck. Of the fractures belong- 
ing to the lower third, 22 were through the internal condyle, 29 through the 
external condyle, 18 were at the base of the condyles, 6 through the condyles 
and across the base at the same time; 1 at the epiphysis; the remaining 27 
being through the shaft, but above the base. 

§ 1. Fractures of the Head and Anatomical Neck. (Intracapsular ; 
Non-impacted and Impacted.) 

Fractures of the Head are due to the penetration of balls or of other 
missiles directly into the joint, producing thus a compound, and gen- 
erally comminuted, fracture of the head ; and to falls, or direct blows 
upon the shoulder, without penetration. When the fracture results from 
the direct penetration of some foreign body into the joint, it is not only 
a compound fracture, but the head of the bone is almost necessarily 
broken into many fragments. If the patient recovers, sooner or later 
the fragments have generally to be removed, or resection has to be prac- 
tised. Examples of fractures of the head of the humerus, not caused by 
penetrating injuries, and not accompanied with fracture of the ana- 
tomical neck, or of the tubercles, are very rare. Nevertheless now and 
then a specimen has been found for which this distinction has been 
claimed ; in most of which the fracture has been of the nature of a 
simple fissure. 

Gosselin describes a case in which there were two fissures extending through 
the articular cartilage, and about one centimetre into the spongy structure. The 
joint contained half an ounce of blood ; death having occurred fourteen hours 
after an accident the exact character of which was not determined. 1 Malgaigne 
has described a similar case, in which there were two fissures, one horizontal in 
its direction, and the other vertical. 2 Gross refers to a case of single fissure of 
the head, which had become consolidated. 3 Howe speaks of a specimen in the 

1 Gosselin, Gurlt. 

2 Malgaigne's Atlas, pi. 4, fig. 2. (In the text, vol. i. p. 526, only one fissure is described.) 

3 Gross, Treatise on Surg., 1st ed., vol. ii. p. 190. 



FRACTURES OF THE HEAD AND ANATOMICAL NECK 



!07 



Dupuytren museum in which about one-third of the head had been broken off 
and united. He also refers to another specimen in the same collection which 
Lenoit regarded as a fracture of the anatomical neck and which was ununited. 1 
Examples in which the fracture of the head is accompanied with a fracture of 
the anatomical neck, or of the tubercles, are much more frequently observed. 

Fractures of the Anatomical Neck sometimes follow, with a remark- 
able degree of accuracy, the line of the insertion of the capsular liga- 
ment, being always, according to Robert Smith, within the interior or 
outer margin of this insertion. He calls them, therefore, intracapsular. 
It is probable, however, since, as we shall presently see, bony union is 
not denied to certain supposed examples of this fracture — that the line 
of separation is not always, or generally, perhaps, completely within the 
insertion of the ligament, but that it is in some degree extra-articular, if 
not extracapsular. 

Boyer says that he has seen several examples of this fracture, none of which, 
however, was accurately diagnosticated until after death. He observes that the 
specimens which have been fully recognized as intracap- 
sular, would seem to show that the superior fragment con- 
tributes almost nothing to the process of repair, but that, 
as in the case of intracapsular fractures of the neck of the 
femur, they are subjected to a process of partial absorp- 
tion. He further illustrates the correctness of these con- 
clusions, by reference to a case examined in the autopsy 
seven days after the accident, in which the head had al- 
ready suffered a remarkable diminution by the process of 
absorption. He quotes, also, two cases described by 
Reichel, in which union had taken place, and the exact 
line of fracture could not, therefore, be so accurately de- 
termined. 2 

Mr. Spence exhibited a specimen to the Medico-Chir- 
urgical Society of Edinburgh, May 2, 1860. A man ad- 
vanced in life, in consequence of a fall, sustained a frac- 
ture. He died a^ the end of four weeks, from apoplexy. 
The fracture was found in the autopsy to have passed 
"through the anatomical neck;" — that is, between the 
head and tuberosities, and within the capsular ligament. 
No union had taken place. 3 

Gibson, also, thinks that the fragment occasionally re- 
mains without becoming necrosed, or causing suppurative 
action, being gradually absorbed and changed in figure. 
He says that his museum contains three or four well- 
marked cases of this kind, in all of which the head has lost its spherical form, 
and is very much diminished, and rough and flattened next to the scapula. 4 
Other cabinets are said to contain similar specimens. 

The displacements to which the upper fragment, or the head of the 
bone, is subject, are remarkable, and some of them do not seem to be 
satisfactorily explained. Frequently, indeed, its position is not sensibly 
disturbed, but at other times it is found impacted, or driven into the 
cancellous structure of the inferior fragment, in consequence of which 
one or both of the tubercles are frequently broken off. 

1 Howe, Gaz. des Hop., 1858, p. 272. 

2 Boyer, Trait, des Mai. Chir., 4th. ed., 1831, vol. iii. p. 199. 

3 Spence, Ed. Med. Journ., vol. v. p. 1140, 1860. 

4 Gibson, Elements of Surgery, vol. i. p. 279. 




Fracture of the ana- 
tomical neck. 



208 



FRACTURES OF THE HUMERUS. 



Robert Smith relates the following case as having afforded him his first oppor- 
tunity of ascertaining by post-mortem examination the exact nature of this 
form of displacement : " A female, set. forty-seven, was admitted into the Eich- 
mond Hospital, under the care of the late Dr. McDowell, for an injury to the 
humerus, the result of a fall upon the shoulder. Five years afterward, the 
woman was again admitted, under the care of Mr. Adams, with an extracapsular 
fracture of the neck of the femur, one month after the occurrence of which she 
died, in consequence of an attack of diarrhoea. The shoulder was of course 
carefully examined ; the arm was slightly shortened, the contour of the shoulder 
was not as full or round as that of its fellow, and the acromion process was more 
prominent than natural. Upon opening the capsular ligament, the head of the 
humerus was found to have been driven into the cancellated tissue of the shaft, 
between the tuberosities, so deeply as to be below the level of the summit of the 
greater tubercle ; this process had been split off, and displaced outward ; it 
formed an obtuse angle with the outer surface of the shaft of the bone." 1 



Fig. 97. 



Fig. 98. 




Penetration of fragments in fracture at the anatomical neck. 

Two excellent drawings (Figs. 97 and 98) of the specimen show the distance to 
which the superior fragment had penetrated the inferior, and show also com- 
plete union by bone. 

[The penetration in these cases is rather of the shaft into the cancellated 
tissue of the head of the humerus.] 

I believe, also, that in the following example there was a fracture at or near 
the anatomical neck, with impaction, and splitting of the tubercles : A young 
man fell from a height in a gymnasium, severely injuring his left shoulder. I 
saw him soon after the accident, and found him complaining very much of the 
shoulder, which was somewhat swollen and tender. He could not tell how he 



1 R. Smith, Fractures in Vicinity of Joints, pp. 191-3. 



FKACTUKES OF THE HEAD AND ANATOMICAL NECK. 209 

fell, nor could we discover any contusions by which to determine the point 
where the blow was received. All motions of the shoulder-joint were painful ; 
and there was a remarkable fulness in front of the joint, feeling like the head of 
the bone, yet not such as is usually present in a forward luxation, To determine 
this more positively, however, the limb was manipulated as for the reduction of 
a dislocation. Once during the manipulation a feeble but distinct crepitus was 
detected ; yet the position of the bone remained unchanged. The head was 
found to be in the socket, but the precise nature of the injury was not made out. 
Fifteen days later, when the swelling had completely subsided, a careful exam- 
ination was again made, when we arrived at the conclusion that it was a fracture 
through the bicipital groove, and that the lesser tubercle was carried forward 
half an inch or more from its fellow, while the head and the greater tubercle 
occupied their natural positions opposite the socket. The fragment projecting 
in front presented a sharp point, and could not be confounded with any swelling 
of the soft parts. There was a distinct space between the tubercles, into which 
the finger could be laid. No depression existed under the acromion process 
behind, but, on measurement, the head of the humerus was found to be half an 
inch wider in its antero-posterior diameter than the opposite. That this frac- 
ture was accompanied with impaction was rendered certain by the repeated and 
careful measurements of the length of the humerus, which constantly showed a 
shortening of half an inch. 

Under these circumstances union generally takes place ; but it is 
usually accompanied with the formation of an irregular mass of osteo- 
phytes, which encircle the head like a coronet ; presenting in this respect 
again a remarkable resemblance to extracapsular fractures of the neck 
of the femur. This ensheathing callus, as it may be called, is an out- 
growth from the inferior fragment, and it sometimes incloses the upper 
fragment as the case of a watch incloses the crystal, only in a manner 
much more irregular, thus retaining it steadily in its place, although very 
little direct union has occurred. The cancellous tissue, nevertheless, is 
occasionally found united completely by a new T and intermediate bony 
tissue, and at other times by a fibrous tissue, or by both fibrous and bony 
tissue. 

In some cases a perfect false joint has been formed between the oppos- 
ing surfaces ; while in a few unfortunate examples the head not only 
refuses to unite, but by its presence, as we have already remarked, pro- 
duces inflammation and suppuration, resulting in its final extrusion from 
the joint. At other times the upper fragment turns upon its own axis, 
and is found more or less tilted or completely rotated in the socket ; so 
that its cartilaginous or articulating surface rests upon the broken surface 
of the lower fragment, and its own broken surface presents toward the 
glenoid cavity. 

Robert Smith has described a specimen of this kind which he removed from 
the body of a woman, aged forty, who many years previous to her death fell 
down a flight of stairs, and struck her shoulder with great violence against the 
edge of one of the steps. Whether she applied to a surgeon or not at the time 
of the accident, Mr. Smith was not able to ascertain. After death the shoulder 
looked somewhat as if there was a dislocation of the humerus into the axilla, 
there being a marked depression under the acromion process, but the shaft of the 
humerus was drawn upward and inward toward the coracoid process. When 
the capsular ligament was opened, the head of the bone was found to have been 
broken from the shaft through the line of the anatomical neck, and to have com- 
pletely turned upon itself; and the cartilaginous surface was actually driven one 
inch into the cancellated structure of the shaft, so as to split off the lesser 
tubercle with a portion of the greater. Only one-half of the upper fragment 

* 14 



210 



FRACTURES OF THE HUMERUS. 



was thus impacted, the other half projecting beyond the margin of the lower 
fragment. Between the cartilaginous surface and the shaft no union had 
occurred ; but there was complete bony union between the upper and lower 
fragments, beyond the limits of the cartilage. (Fig. 99.) The upper surface 
of the superior fragment rested in part against the inner half of the glenoid 
cavity and upon its inner margin, and in part it rested against the neck of the 
scapula in the direction of the coracoid process. 1 



Fig. 100. 



V 



Fig. 101. 



Fig. 99. 




Fracture through the tuberosities 
of the humerus and reversal of the 
head. (R. W. Smith.)' 



mm 
I 



.; ---=■• 



Dr. Pope's specimen. 
Front view. Side view. 

Nelaton saw a similar specimen in the possession of M. Dubled, the revolution 
of the upper fragment being complete ; but there was no lateral displacement, 
and the union had been accomplished in a manner similar to that which is seen 
after intracapsular, impacted fractures, without reversion. 2 

I have also been permitted to examine a specimen belonging to the late Dr. 
Pope, of St. Louis, Mo., which seems to have been broken not only through the 
line of the anatomical neck, but also through the surgical neck. Both fragments 
are united by bone, the lower fragment being carried in the direction of the 
coracoid process, while the upper fragment appears to be reversed, so that its 
articular surface is directed toward the shaft, and its broken surface articulates 
with the glenoid cavity. The history of this specimen is unknown. 

Reverting to the histories of the several cases above referred to, in 
which these extraordinary changes of position have taken place, it would 



1 R. Smith, op. cit., pp. 193-6. 

2 Nelaton, Elements de Pathol. Cb.ir.ur., torn, prem., p. 30' 



FKACTURES THROUGH THE TUBERCLES. 211 

seem to admit of a doubt whether they were the direct results of the acci- 
dents which broke the bones, or whether they ensued indirectly, in con- 
sequence of a chronic arthritis following the accident, and the constant 
but long-continued use of the arm, and muscular contraction. There is 
another theory which, in my opinion, is capable of explaining most of 
the phenomena presented in some or all of those cases in which union of 
the fragments is claimed to have taken place, and which, if admitted, 
renders the supposition of a fracture unnecessary. It is, that in conse- 
quence of an injury, perhaps, but not of a fracture, chronic inflammation, 
softening and absorption have taken place, and that the changed position 
of the head is due to pressure alone, being acted upon by the muscles 
which surround the joint, and which act all the more vigorously because 
they partake also of the inflammation which has invaded the bone. 

This theory, which had already more than once suggested itself to me, was 
very strongly confirmed by its having occupied the mind also of Dr. Neill, of 
Philadelphia, and who, at his own instance, stated to me that he believed this 
was their true explanation. We were, at the time, examining Dr. Pope's speci- 
men, already alluded to, and on comparing it with a specimen of dislocation 
and partial absorption of the head of the humerus contained in Dr. Neill's 
museum, the points of resemblance were so numerous and striking that we felt 
compelled to doubt whether Dr. Pope's specimen, together with those seen by 
Smith and Nelaton, did not belong to the same class with this of Neill's. Other 
writers have reported similar cases. 

I do not mean to deny the possibility of bony union under these cir- 
cumstances, but only to suggest that such an occurrence would seem to 
be very improbable, and that its actual occurrence does not seem at 
present to be absolutely proved. If union by bone is improbable when 
the head of the femur is broken within the capsule, how much more 
improbable must it be when the head of the humerus is thus broken ; in 
which latter case there is not even the poor supply of nutrition furnished 
to the head of the femur by the round ligament. 

In a case of fracture of the " cervix humeri within the capsular ligament," 
examined by Sir Astley Cooper, there was also a complete forward luxation of 
the head ; but ligamentous union had occurred between the fragments. 1 

§ 2. Fractures through the Tubercles. (Extracapsular ; Non-impacted 

and Impacted.) 

Under this division w*e intend to speak of all fractures traversing the 
upper end of the humerus, and involving the tubercles ; or of all those 
which occur between the anatomical neck on the one hand, and the epi- 
physeal junction, or surgical neck, on the other hand, and which may be 
more or less oblique as well as transverse. Fractures of the greater or 
lesser tubercles are, of course, expected, since they are more properly 
longitudinal fractures, and do not completely traverse the diameter of the 
bone. Nor do we intend to include those fractures which occur at the 
epiphyseal junction; since, being below the principal insertion of those 
muscles which are attached to the tubercles, they present very peculiar 

1 Sir A. Cooper on Dislocations, etc., p. 372. 



212 FRACTURES OF THE HUMERUS 

and distinctive features, which will demand for them a separate classifi- 
cation and consideration. 

Causes, Pathology, and Results. — Fractures through the tubercles, 
like fractures through the anatomical neck, are the results generally of 
direct blows received upon the shoulder. They are not usually accom- 
panied with much lateral displacement at the point of fracture ; a cir- 
cumstance which finds a partial explanation in the fact that the line of 
fracture is through the insertions of the muscles converging upon the 
tubercles, and not entirely above or below them, so that they continue to 
act nearly equally upon both fragments ; but it is also sometimes due in 
a measure to impaction : the head being forced downward toward the 
axilla, and upon the shaft, until it is made to ride upon its inner or axil- 
lary wall like a cap ; the compact bony tissue of the shaft penetrating 
the reticular structure of the head. These fractures generally unite by 
bone ; yet more or less impairment of the motions of the limb results 
from the inflammation which occurs in and about the joint, or from the 
irregular deposits of callus in the vicinity of the fracture. 

§ 3. Longitudinal Fractures of the Head and Neck ; or Splitting off of 
the Greater Tubercle. 

Causes, Pathology, Symptoms, and Results. — Mr. Guthrie seems to 
have been the first to call attention to this peculiar injury of the shoulder. 
In a lecture delivered in November, 1833, he described four cases which 
had come under his observation, and which he regarded as examples of 
separation of the small tuberosity, accompanied with more or less of the 
head, the fracture extending along a portion of the bicipital groove. 1 
Robert Smith, however, believes that it was the greater and not the 
lesser tuberosity which was thus detached in the cases mentioned by Mr. 
Guthrie, since the external signs were so nearly like those which were 
present in a woman seen by himself, and in whom an autopsy enabled 
him to verify his diagnosis. 

The following is the case as related by Mr. Smith: In July, 1844, I. was 
requested to examine the body of J. D., eet. eighty years, who had died of chronic 
pulmonary disease. Upon entering the room, the appearances of the left shoul- 
der-joint at once attracted my attention, and struck me as being different from 
those which attend the more common injuries of this articulation. The shoulder 
had lost, to a certain extent, its natural rounded form ; the acromion process, 
although unusually prominent, did not project as mirch as in cases of disloca- 
tion of the head of the humerus. The breadth of the articulation was greatly 
increased, and, upon pressing beneath the acromion, an osseous tumor could be 
distinctly felt, occupying the greater part of the glenoid cavity ; it formed a 
prominence which was perceptible through the soft parts; it moved along with 
the shaft of the humerus, but was manifestly not the head of the bone. . 

"A second and larger tumor, presenting the rounded form of the head of the 
humerus, lay beneath the base of, and internal to, the coracoid process, and 
between the two the finger could be sunk into a deep sulcus, placed immediately 
below the coracoid process. The elbow could be brought into contact with the 
side, and there was no appreciable alteration in the length of the arm. Upon 
removing the soft parts, the head of the bone presented itself, lying partly be- 
neath and partly internal to the coracoid process. The greater tuberosity, 

1 Robert Smith, p. 181, from Lond. Med. and Phys. Journal. 



FRACTURES THROUGH THE SURGICAL NECK. 213 

together with a very small portion of the outer part of the head of the bone, 
had been completely separated from the shaft of the humerus. This portion of 
the bone occupied the glenoid cavity, the head of the humerus having been 
drawn inward so as to project upon the inner side of the coracoid process; it 
was still, however, contained within the capsular ligament. The fracture trav- 
ersed the upper part of the bicipital groove, which, in consequence of the dis- 
placement which the head of the bone had suffered, was situated exactly below 
the summit of the coracoid process. A new and shallow socket had been formed 
upon the costal surface of the neck of the scapula, below the root of the coracoid 
process, and the inner edge of the glenoid cavity corresponded to the posterior 
part of the sulcus which separated the head of the bone from the detached tube- 
rosity. The latter was united to the shaft only by ligament. The capsule had 
not been injured, but was thickened and enlarged, and the bone had been depos- 
ited in its tissue. The injury had evidently occurred many years before the 
death of the patient, but the history connected with it couid not be precisely 
ascertained." 1 

The following I believe also to have been an example of this rare accident : 
J. H., aet. seventy-eight, fell upon the sidewalk, striking upon his right shoul- 
der. Eight days after, Dr. Boardman and myself examined the limb carefully. 
Although we placed him under the influence of chloroform, the diagnosis was 
not satisfactorily made out. We inclined, however, to the opinion that it was a 
fracture of the greater tubercle. The antero-posterior diameter of the upper 
end of the bone was greatly increased ; there was occasional distinct crepitus, 
but the limb was not shortened. 

Subsequently, the examinations were repeated many times, and the depres- 
sion between the fragments becoming more palpable, the diagnosis was at length 
confirmed. 

Dr. Charles, demonstrator of anatomy, Queen's College, Belfast, has reported 
a case with great care. The man was thirty years old, and it is supposed that 
the middle of the head of the humerus was struck by the pole of a tram-car. 
Dr. Charles examined the patient fourteen months after the receipt of the in- 
jury; the breadth of the head Of the humerus was greatly increased, there was 
a broad sulcus in the situation of the bicipital groove, and the humerus was 
shortened half an inch. The motions of his arm were very much limited, espe- 
cially in abduction. 2 

Mr. Robert Smith thinks that when the displacement is considerable, the 
fragments generally unite by ligament, rather than by bone. 

§ 4. Fractures through the Surgical Neck. (Including Separations 
at the Upper Epiphysis.) 

I have already denned the "surgical neck" as all of that narrow por- 
tion commencing at the upper epiphysis and terminating at the insertion 
of the pectoralis major and latissimus dorsi. It seems proper, therefore, 
that we should include under this division both fractures and separations 
occurring at the epiphysis, especially since, owing to their anatomical 
relations, they are subject to the same displacements as fractures occur- 
ring half an inch or one inch lower down ; the capsular muscles, with 
the exception of the teres minor, having no more influence over the lower 
fragment when a separation occurs at the epiphysis, than when a separa- 
tion occurs at any other point of the surgical neck. 

Separation at the Upper Epiphysis. — A brief description of the plan 
of development of the humerus will enable the reader better to under- 
stand the occasional separation of the epiphysis, both at the upper and 
lower ends of the bone. 

1 Robert Smith, op. eit., p. 178. 

2 J. J. Charles, British Med. Journ., Sept. 26, 1874. 



214 



FRACTUKES OF THE HUMERUS. 



Fig. 102. 



The humerus is originally formed from seven cartilaginous centres, namely, 
one for the shaft, one for the head, one for the greater tuberosity, one for each 
epicondyle, and two for the lower, articulating end of the bone. At birth the 
shaft is ossified in nearly its whole length. Between the first and fourth years 
ossification commences in the several centres composing the upper end of the 
bone, and they coalesce by the end of the fifth year, so as to form a single epi- 
physis, which finally unites with the shaft at about the twentieth year. At the 
lower end of the bone, ossification commences in the radial portion of the artic- 
ular surface at the end of two years, in the trochlear portion at twelve years, in 
the internal epicondyle at the fifth year, and in the external epicondyle at the 
thirteenth or fourteenth. At the sixteenth or seventeenth year all the centres 
are joined to each other, and to the shaft, except the inner epicondyle, which 
does not unite by bone until about the eighteenth year. 
It will be observed, therefore, that although ossification 
commences in the upper epiphysis first, it is the last to 
form bony union with the shaft. 

The following cases of separation at the upper epiph- 
ysis have come under my notice : 

Case 1. — M. E., set. thirteen months, fell sideways 
from his cradle, causing some injury to his arm near 
the shoulder. Three weeks after the accident he was 
brought to me, and I found the arm hanging beside the 
body, with little or no power on the part of the child to 
move it. There was a slight depression below the acro- 
mion process, and considerable tenderness about the 
joint; but the shoulder was not swollen, nor had it 
been at any time. The line of the axis of the bone, as 
it hung by the side, was directed a little in front of the 
socket. On moving the elbow backward and forward, 
the upper end of the shaft moved in the opposite direc- 
tions with great freedom, and could be distinctly felt 
under the skin and muscles. This motion was accom- 
panied with a slight sound, or sensation — a sensation 
not unlike the grating of broken bone, but much less 
rough. There was no shortening of the limb. When 
the elbow was carried a little forward upon the chest, 
the fragments seemed to be restored to complete coapta- 
tion ; and of this I judged by the restoration of the line 
of the axis of the shaft to the centre of the socket, and 
by the complete disappearance of the depression under 
the point of the acromion process. I applied suitable 
dressings to retain the arm in this position ; but five 
months after the injury was received the fragments had 
not united, and the child was still unable to lift the 
arm, although the forearm and hand retained their usual 
strength and freedom of motion. The same crepitus 
could occasionally be felt in the shoulder, and the same 
The shoulder was at this time neither swollen nor 




v Py — <*_y 

Humerus, with epiphyses. 
(From Gray.) 



preternatural mobility, 
tender. 

Case 2. — S. E., set. thirteen, fell through a hatchway, striking on his shoul- 
der. He saw a regular physician within five hours after the injury was received, 
who said that the arm was dislocated; and on the following day, under the 
influence of chloroform, he tried to reduce it. The doctor thought he had suc- 
ceeded, and he then applied bandages to keep it in place. At the end of two 
weeks I found the upper end of the lower fragment projecting in front, and not 
united. The arm was shortened half an inch. I have not seen the patient since, 
and do not know the result. 

Case 3. — J. S., set. sixteen, fell backward down a flight of steps, striking upon 
his back and arm near the shoulder, May 10, 1868, causing a separation of the 

upper epiphysis of the left humerus. Dr. saw the patient within half an 

hour, and supposing that he had suffered a dislocation of the head of the 
humerus, attempted to effect reduction with his heel in the axilla, and without 



FRACTUKES THROUGH THE SURGICAL NECK. 



215 



anaesthetics. On the following day I found him in Bellevue. All efforts at 
replacement proving ineffectual, splints were applied, and on the 15th of July 
the patient left the hospital with the fragments united, but overlapped at the 
point of fracture, the upper end of the lower fragment being in front of the 
upper fragment. The limb was shortened one inch, but its motions were free, 
and there was no reason to suppose that its utility was in any degree impaired. 

Fig. 103. 





Separation of upper epiphysis of humerus from the shaft. (Bryant.) 

Case 4. — C. H., set. nineteen, fell from a third-story window. Two very 
intelligent and experienced physicians thought the boy had received a fracture 
of the acromion process, accompanied with a dislocation of the head of the 
humerus, and they attempted to reduce it, but without success. Three weeks 
after the receipt of the injury I saw the patient in consultation with his physi- 
cians, and found a separation of the upper epiphysis of the humerus. The upper 
end of the lower fragment projected in front of the acromion process, appearing 
a little above the level of the process, and covered only by the skin. No union 
had occurred between the two fragments. 

Case 5. — J. D., set. eighteen, fell about eight feet. Of the three surgeons first 
called, two thought the boy had received a fracture ; the third believed it to be 
a dislocation, and having placed the patient under the influence of ether, 
attempts were made to reduce it. The deformity not being relieved, I was 
added to the consultation. I found the shoulder a good deal swollen. The 
upper end of the lower fragment could be felt distinctly in front of the acromion 
process. At first, the surgeons informed me, the broken end seemed just under 
the skin and almost ready to be thrust through, but the extension had made it 
retire somewhat. The end felt rough and serrated. While making extension I 
was able to detect a slight crepitus or click. Employing Dugas's test, I found 
the elbow would rest upon the front of the chest; the diagnosis was complete. 
Applied one long splint, and a sling under the wrist, but not under the elbow. 
The fragments have united with very little deformity. 1 

The following case, mentioned by Robert Smith, is a characteristic example: 
"A boy, eight years of age, was admitted to the Richmond Hospital. About 
a week previous to his admission he had fallen upon the shoulder, and at 
once lost the power of using his arm. It was at first sight evident that there 
did not exist any luxation of the head of the humerus, and it was equally 
obvious that the case was not an example of any of the ordinary fractures to 
which the neck of the bone is liable. There was no diminution of the natural 
rotundity of the shoulder, nor any unusual prominence of the acromion process; 
the head of the bone could be distinctly felt in the glenoid cavity, and it 
remained motionless when the arm was rotated ; there was very little separation 
of the elbow from the side, but it was directed slightly backward. About three- 
quarters of an inch below the coracoid process there existed a remarkable and 
abrupt projection, manifestly formed by the upper extremity of the shaft of the 
humerus, every motion imparted to which it followed. Its superior surface, 



Medical Record, May 1, 1S74. 



216 



FRACTURES OF THE HUMERUS. 



which could be distinctly felt, was slightly convex, and its margin had nothing 
of the sharpness which the edge of a recently broken bone presents in ordinary 
fractures. When this projecting portion of the bone was pushed outward, so as 
to bring it in contact with the under surface of the head of the humerus (pre- 
viously fixed as far as it was possible to do so), a crepitus was produced by rotating 
the shaft of the bone. It did not, however, resemble the ordinary crepitus of 
fracture, but it would be extremely difficult, by any description, to convey a 
clear idea of what the difference consisted in. From a careful consideration of 
the symptoms and appearances above mentioned (taking into account also the 
age of the patient), the diagnosis was formed, that the injury consisted in a 
separation of the superior epiphysis of the humerus from the shaft of the bone. 
Various mechanical contrivances were employed in this case, but all proved 
ineffectual in maintaining the fragments in their proper relative position." 1 

Fig. 104. 




Appearance after separation of the upper epiphysis of the humerus. (R. W. Smith.) 

According to Malgaigne, 2 Bertrandi found this condition in a child born dead, 
and Durocher reported a case, in which it was produced at birth by a midwife, 
who had hooked her finger into the armpit to expedite the delivery. 

Prof. E. M. Moore, of Rochester, observes that the displacement is not usually 
complete ; but that the upper end of the lower fragment is carried inward to the 
distance of about one-fourth of its diameter, when it is arrested, by a convexity 
of the lower fragment becoming lodged in a natural concavity in the upper frag- 
ment. The upper fragment now becomes tilted by the action of the muscles, its 
internal margin ascending in the glenoid cavity, and its outer margin descending 
until it is arrested by the capsule. If, under these circumstances, the arm is 
carried forward and upward to the perpendicular line, the upper fragment or 
epiphysis will remain fixed, being held fast by the capsule inserted into the 
outer and posterior margin of the head, while the lower fragment or diaphysis, 



1 Robert Smith, op. cit., p. 201. 

1 Bertrandi, Durocher, Malgaigne, op. cit., t. i. p. 60. 



FRACTURES THROUGH THE SURGICAL NECK 



217 



aided by the natural action of the muscles, will move outward and resume its 
original position. The correctness of this opinion he has verified by having in 
this manner effected the reduction with great ease, in three cases which have 
come under his observation. The patients were respectively six, fourteen, and 
sixteen years of age. In the first case the reduction was effected on the four- 



Fig 105. 




Fig. 106. 





Upper epiphysis of humerus. (From Moore.) Epiphyseal separation. (From Moore.) 



Fig. 107. 



teenth day ; in the second case, on the second day ; and in the third, on the 
seventeenth day. In both of the latter, ineffectual attempts had been already 
made to reduce what was supposed to be a dislocation. In order to maintain 
the reduction, it was only found necessary to 
bring the arm down while in a state of moderate 
extension, and to secure it beside the body with 
a Swinburne extension splint. Any of the forms 
of dressing applicable to a fracture of the surgi- 
cal neck would probably prove equally efficient. 

The observations made by Professor Moore 
seem to me exceedingly valuable; yet I do not 
think it always happens that the separation is 
incomplete, nor does Professor Moore say that it 
is, but that was the condition in all the cases 
seen by him. Professor Pooley, of Columbus, 
Ohio, reports a case occurring in a boy twelve 
years old, which he was unable to reduce by 
Moore's method. Dr. Richmond reports another 
example in a youth nineteen years old suc- 
cessfully reduced by this method. In three cases 
reported by myself, the upper end of the lower 
fragment was above the level of the coracoid 
process, and seemed to be directly beneath the 
skin. These were probably examples of com- 
plete separation ; three presented the symptoms 
described as characteristic of the partial separa- 
tion in Professor Moore's paper; the projection 
was less marked, and on a level with the cora- 
coid process, or a little below it. In all my cases, except the first, the upper 
end of the lower fragment could be felt, not sharp or pointed, as in most exam- 
ples of fracture of the surgical neck, but somewhat irregularly transverse, and 




Fracture of the surgical neck of 
the humerus. (From Gray.) 



218 FRACTURES OF THE HUMERUS. 

when covered with the skin and muscle, might be easily mistaken, by the inex- 
perienced, for the head of the bone. 

True Fracture of the Surgical Neck. — The various features of this 
fracture may best be illustrated by the following cases. 

Case 1. Simple fracture ; union, ivith displacement and deformity. — W., set. 12, 
fell fourteen feet, striking on the front and outside of the left shoulder. He was 
brought to me on the fourth day after the accident. The upper part of the arm 
was then very much swollen ; was dressed as for a fracture of the middle or 
lower third of the humerus ; shortened one inch; elbow inclined backward, and 
there was a remarkable projection in front of the joint, feeling like the head of 
the bone; the hand and arm powerless; suspected a dislocation of the head of 
the humerus forward ; having administered chloroform, attempted its reduction 
with heel in the axilla ; while making extension, felt a sudden sensation like the 
slipping of the bone into the socket, but on examination found the projection 
continued as before ; repeated the effort, with precisely the same result. Five 
days after the accident, it was examined ; still believed it was a dislocation, and, 
having administered chloroform, again attempted its reduction ; the same slip- 
ping sensation was produced as before, and the deformity was repeatedly made to 
disappear; but, on suspending the extension, it as often reappeared. The char- 
acter of the accident was now made apparent ; proceeded at once to apply a 
gutta-percha splint, extending, on the outside, from the top of the shoulder to 
below the elbow, with an arm and body roller secured with flour paste ; twelve 
days after the accident, fragments were displaced the same as when I first saw- 
it, and the same as when no apparatus was applied; examined it again carefully, 
and attempted to make the fragments remain in place, but was unable to do so, 
except while holding them and making extension. Twenty-first day removed 
all the dressings; motion between the fragments had ceased, but the projection 
and shortening remained as before; now, also, the irregular projections of the 
fractured bones were more distinctly felt. The dressings were never reapplied. 
Three months later no change had occurred. He could carry the elbow forward 
freely, as well as backward, the motions of the shoulder-joint being unimpaired. 

Case 2. Simple fracture, with displacement ; resulting in deformity and non-union. 
— L. B., of Lockport, set. 43, was thrown from his horse, striking upon his right 
elbow. Three surgeons, who examined the arm, called it a dislocation. Twelve 
weeks after the accident, Mr. B. called upon me. The right arm was shortened 
one inch ; the elbow hung off slightly from the body; the upper end of the lower 
fragment was distinctly felt in front of the shoulder-joint, under the clavicle, 
feeling very much like the head of the bone. The fragments were not united, 
but they could be seized easily, and made to move separately and freely. . Two 
years after, I found the bone still ununited. 

Case 3. Simple fracture, probably impacted: resulting in deformity. — Wm. 
A., set. 15, fell backward, striking upon his back and left shoulder. Dr. L. 
saw the case immediately, and, regarding it as a dislocation, attempted its 
reduction. He subsequently repeated the attempt. I saw the patient with Dr. 
L. on the tenth day. The arm was shortened one inch and a half. The frag- 
ments were displaced forward, projecting in front of and a little below the joint; 
it might easily be mistaken for the head of the bone; but the difficulty of diag- 
nosis had been very much lessened by the subsidence of the swelling. There 
was no motion between the fragments ; nor could the deformity, by any manipu- 
lation or extension, be made to disappear. It was probably impacted. . Nearly 
ten months after the accident, I found the fragments remaining as when I first 
examined the limb, and the arm shortened one inch and a half. The elbow 
hung a very little back from the line of the body. The upper end of the lower 
fragment was lifted to within one inch of the head of the humerus; the upper 
fragment having its head in the socket, with its lower end downward and forward. 
The arm was, however, in every respect as useful as before it was broken. It 
was equally strong, and he could raise his arm as high and move it in every 
direction as freely as he could the other. 



FRACTURES THROUGH THE SURGICAL NECK. 219 

Causes. — Epiphyseal separations belong almost exclusively to the 
period of youth and childhood, but true fractures at the surgical neck 
occur most often in adult life. 

With the exception of one girl and two lads, aged, respectively, eleven, twelve, 
and fifteen years, all of the examples of this latter accident recorded by me 
(forty-four) occurred in adults ; yet Sir A. Cooper declares these fractures to be 
most common in infancy, while Malgaigne has never seen a case in a person 
under fifty-three years. 

Both epiphyseal separations and fractures at this point are occasioned, 
in most cases, by direct blows or falls upon the shoulder. 

Of thirty-one examples in which I find the cause recorded, twenty-two were 
from direct blows, eight from indirect blows, and one from muscular action, as 
in throwing a ball. Of the eight resulting from indirect blows, one was from a 
fall upon the hand, seen by Desault, and seven were from falls upon the elbow, 
of which two were seen by Desault, and five by myself. 

Pathology. — I have found the fragments sensibly displaced in twelve 
cases out of seventeen ; a proportion much greater than has been ob- 
served by Malgaigne, who has only seen a displacement twice in more 
than twenty cases. It is certain, however, that complete or sensible 
displacement is less common in this fracture than in most other fractures, 
the broken ends being retained in place, probably, by the long tendon of 
the biceps and the long head of the triceps. As to the direction of the 
displacement, I have generally found the upper end of 'the lower frag- 
ment drawn forward and upward toward the coracoid process; in one of. 
which examples the upper fragment plainly followed the same direction. 

Sir Astley Cooper declares that with infants this direction is constant, and in 
museum specimens I have seen but one exception. In the specimens of fracture 
of the surgical neck, with also displacement of the head, belonging to Dr. Pope, 
this direction of the fragments is plainly seen, as also in one of the specimens 
belonging to Dr. Neill, of the Pennsylvania Medical College, where the lower 
fragment almost reaches the coracoid process, and in a specimen contained in 
one of the cabinets of the University of Pennsylvania, where the upper end of 
the lower fragment has become united by bone to the coracoid process. The 
only exception which I have met with is in the possession of Dr. Neill. In this 
example the two ends are tilted toward the axilla. I am compelled, therefore, 
to doubt the accuracy of Malgaigne's observations, who thinks he has seen the 
lower fragment most often drawn toward the axilla, as well as the observations 
of those who think that the upper fragment is generally displaced outward; yet, 
no doubt, they do sometimes assume this position. Desault has seen them 
both thrown backward ; while Dupuytren, Paletta, and others have seen them 
pushed outward; and I have in my collection the copy of a specimen in which 
both fragments are drawn outward, but the lower fragment is to the inner side 
of the upper. 

When the fracture occurs at or near the epiphysis, it is sometimes 
accompanied with impaction, of the same character as we have already 
described when speaking of fractures through the tubercles. 

Eobert Smith has given, in his treatise, an engraving intended to illustrate 
the relative position of the fragments in extra-capsular impacted fractures, and 
the line of separation very nearly corresponds to the line of junction of the 
epiphysis with the shaft. But in a majority of cases no impaction occurs. Dr. 
Charles A. Pope, of St. Louis, Mo., has two specimens of this kind, in which no 



220 FRACTURES OF THE HUMERUS. 

union has taken place, nor is there any evidence that impaction had ever oc- 
curred, la one case the line of fracture commences at the junction of the head 
with the shaft, and extends thence irregularly across to a point half an inch 
below the greater tuberosity. In the second specimen the fracture commences 
at the same point, and terminates three-quarters of an inch below the greater 
tuberosity. In relation to these bones, Dr. Pope remarks : ''These are not cases 
of detachment of the epiphyses, as the bones are evidently those of adults, and 
there is, at their lower extremities above the condyles, no trace of an epiphyseal 
line." 

Prognosis. — Sixteen of the cases of fracture of the surgical neck 
recorded by me are known to have resulted in perfect limbs ; that is to 
say, there is no displacement, overlapping, or shortening, and the patients 
have recovered the free use of the limbs. These were all, probably, 
examples in which no displacement ever occurred. Of the remainder, 
all, so far as I have been able to determine, have united with some dis- 
placement ; but in nearly all the functions of the limb have been fully or 
almost fully restored. The only exception I can recall is the single one 
in which no bony union ever took place. 

[Fracture, with Dislocation of the Head.— This rare complication is con- 
sidered in connection with dislocations of the humerus.] 

Differential Diagnosis of Accidents about the Shoulder-joint. — The 

difficulty of diagnosis in the case of accidents about the shoulder-joint 
has been constantly recognized by surgeons — difficulties which have 
sometimes rendered diagnosis impossible. A dislocation at the shoulder- 
joint is the type with which the other accidents ma,y be compared. 

a. Signs of a Dislocation. ( Cause, generally a fall upon the elbow or hand, 
yet not very unfrequently a direct blow.) 

1. Preternatural immobility. 

2. Absence of crepitus. 

3. When the bone is brought to its place, it will usually remain without the 
employment of force. 

These three are common signs, which apply to any other joint as well as to 
the shoulder. 

4. Inability to place the hand upon the opposite shoulder, or have it placed 
there by an assistant, while at the same time the elbow touches the breast. This 
is a sign Common to all of the dislocations of the shoulder. 1 

The following are special signs, or such as belong only to particular disloca- 
tions of the shoulder : 

5. Depression under the acromion process ; always greatest underneath the 
outer extremity, but more or less in front or behind, according as the dislocation 
may be into the axilla, forward or backward. 

6. Eound, smooth head of the bone sometimes felt in its new situation, and 
very plainly removed from its socket; moving with the shaft. Absence of the 
head of the bone from the socket. 

7. Elbow carried outward, and in certain cases forward or backward, and not 
easily pressed to the side of the body. 

8. Arm lengthened in the subcoracoid and subglenoid dislocations ; and only 
shortened in the subclavicular and subspinous. Occasionally, in old cases, the 
head of the humerus, leaving the subglenoid position, becomes subscapular, 
being placed upon the centre of the scapula, and the arm is shortened. 

1 Report on a New Principle of Diagnosis in Dislocations of the Shoulder-joint, by L. A. 
Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Amer. Med. Assoc, vol. 
x. p. 175. 



FKACTURES THROUGH THE SURGICAL NECK. 221 

b. Signs of a Fracture of the Neck of the Scapula. {Cause, generally a 
direct blow ; exceedingly rare.) 

1. Preternatural mobility. 

2. Crepitus generally detected by placing the finger on the coracoid process, 
and the opposite hand upon the back of the scapula, while the head of the 
humerus is pushed outward and rotated. 

3. When reduced, it will not remain in place. 

4. The hand may generally, but with difficulty, be placed upon the opposite 
shoulder, with the elbow resting upon the front of the chest. 

5. Depression under the acromion process, but not so marked as in dislo- 
cation. 

6. Head of the bone may be felt in the axilla, but less distinctly than in dis- 
location. Never much forward or backward. Head of the bone moves with the 
shaft. Head of the bone not to be felt under the acromion process, although it 
has not left its socket. 

7. Elbow carried a little outward, but not so much as in dislocation. Easily 
brought against the side of the body. 

8. Arm lengthened. 

9. The coracoid process carried a little toward the sternum, and downward. 

10. Pressing upon the coracoid process, it is found to be movable, and it is 
also observed that it obeys the motions of the arm. 

c. Signs of a Fracture of the Lower or Anterior Lip of the Glenoid 
Cavity. Not yet fully determined. 

d. Signs of Fracture of the Anatomical Neck of the Humerus. Intra- 
capsular. {Cause, a direct blow; generally opening to the joint, but not 
always.) 

1. Mobility not increased, nor diminished. 

2. Crepitus, generally discovered by pressing up the head of the bone into 
its socket and rotating ; or, when the tubercles are also broken, by grasping the 
tubercles and rotating the arm. 

3. Fragments not generally displaced. 

4. The hand can be placed easily upon the opposite shoulder, with the elbow 
against the front of the chest. 

5. Very slight, if any, depression under the acromion process. 

6. Head of the bone generally in its socket, but not felt so distinctly as before 
the fracture. 

7. Elbow falls easily against the side of the body, or is easily placed there. 

8. Arm not lengthened, nor appreciably shortened, unless the head be driven 
so much into the body as to separate the tubercles. 

9. In this latter case there are present also the signs of fracture of the 
tubercles. 

e. Signs of Fracture of the Humerus through the Tubercles. Extra- 
capsular. {Cause, direct blows.) 

The signs which characterize this accident are more obscure than in either of 
the other shoulder accidents. They are mostly negative, and will not generally 
be determined positively except in the autopsy. 

1. Generally, there is neither marked mobility nor immobility, except what 
immobility may be due to a contraction of the muscles. 

2. Crepitus, discovered, but not so easily as in intracapsular fractures, by 
rotating the arm while the tubercles are grasped firmly. 

3. If displacement exists, the fragments are not always easily kept in place 
when once reduced. 

4. The hand can be placed upon the opposite shoulder, with the elbow against 
the front of the chest. 

5. No depression under the acromion process. 

6. Head of the bone in its socket, and moving with the shaft, when, as is 
usually the case, it is impacted. 

7. Elbow hangs against the side of the body. 

8. Arm shortened when impacted, but not much. 

/. Signs of a Longitudinal Fracture of the Head and Neck, or Splitting 
off of the Greater Tubercle. {Cause, direct blow upon the front of the 
shoulder.) 



222 FRACTURES OF THE HUMERUS. 

1. Mobility of the limb natural. 

2. Crepitus ; elicited especially by grasping the tubercles and rotating the arm, 
or by carrying it up and back, and then rotating. 

3. When reduced, the fragments will not remain in place. 

4. The hand can be placed upon the opposite shoulder, while the elbow rests 
against the front of the chest. 

5. Some depression under the acromion process. 

6. A smooth bony projection directly underneath the coracoid process, or close 
upon its inner or outer side, moving with the shaft. The head of the bone can- 
not be felt in the socket, yet the space under the acromion is not entirely unoc- 
cupied. 

7. Generally, but not always, the -elbow hangs against the side. Sometimes it 
inclines a little backward. It can always be easily brought to the side. 

8. Arm generally neither lengthened nor shortened. 

9. A remarkable increase in the antero-posterior diameter of the upper end of 
the bone. 

10. A deep vertical sulcus between the tubercles, corresponding with the upper 
part of the bicipital groove. 

g. Signs of a Fracture through the Surgical Neck. {Cause, generally 
direct blows, but in old persons frequently a fall upon the elbow.) 

1. Preternatural mobility often, but not constantly, present. 

2. Crepitus, produced easily when there is no impaction, or when the displace- 
ment is not complete, but with difficulty when impaction exists or the displace- 
ment is complete. 

3. When once the fragments have been displaced, it is exceedingly difficult 
ever afterward to maintain them in place. 

4. The hand can be easily placed upon the opposite shoulder, while the elbow 
rests against the front of the chest. 

5. A slight depression below the acromion, not immediately underneath its 
extremity, but an inch or more below. 

6. Head of the bone in the socket, and moving with the shaft when impacted, 
but not moving with the shaft when not impacted. The upper end of the lower 
fragment being often felt distinctly pressing upward toward the coracoid process ; 
its broken extremity being easily distinguished by its irregularity from the head 
of the bone. 

7. Elbow hanging against the side when the fragments are not displaced, but 
away from the side when displacement exists. 

8. Length of arm unchanged unless the fragments are impacted or overlapped ; 
or both fragments are much tilted inward. If the fragments are completely dis- 
placed, the arm is shortened. 

h. Signs of a Separation of the Epiphysis. {Cause, direct blows,) 

1. Preternatural mobility, 

2. Feeble crepitus ; less rough than the crepitus produced when broken bones 
are rubbed against each other. 

3. Fragments replaced are not easily maintained in place, unless the reduc- 
tion has been effected by Moore's method. 

4. Same as in preceding variety of fracture. 

5. The depression is not immediately under the acromion, yet higher than in 
most fractures of the surgical neck, perhaps one inch below the acromion 
process. 

6. Head of the bone in its socket, and not moving with the shaft. Upper 
end of lower fragment projecting in front, when displacement exists, and feel- 
ing less sharp and angular than in case of a broken bone ; indeed, being 
slightly convex and rather smooth, it may easily be mistaken for the head of 
the bone. 

7. Same as preceding variety. 

8. Length of arm not changed unless the fragments are overlapped, or both 
fragments are tilted upon each other. When the fragments are overlapped, the 
arm is shortened. 

9. This accident is peculiar to the young. It can seldom occur after the 
twentieth year. 



FRACTURES THROUGH THE SURGICAL NECK. 223 

Treatment. — I have already spoken of the treatment of fractures of 
the neck of the scapula, and my remarks will now be confined to fractures 
of the upper end of the humerus. 

Treatment of Intracapsular Fractures of the Neck. — As has been 
stated, these are generally compound fractures, and, from the extent 
of the injury, often demand resection, or amputation of the entire arm. 
If an effort is made to save the arm, splints will not be applied, and the 
treatment will have little or no reference to the existence of a fracture ; 
it will be directed only to the reduction or prevention of the inflamma- 
tion, etc. Simple fracture of the anatomical neck, if not entirely within 
the capsule, without any external wound communicating with the joint, 
and accompanied, as it is sometimes, with impaction, may unite, or the 
upper fragment may become incased in the lower. It is not proper in 
such cases to employ great violence for the purpose of detecting crepitus, 
lest the fragments should become displaced ; and if the arm should be 
found to be a little shortened, it must not be extended, with a view to 
overcoming the shortening, since upon the impaction probably depend, 
in a great measure, the chances of union. The elbow. and forearm may 
be suspended in a sling, while the arm is gently supported against the 
side, merely to insure quietude. No splints are necessary or useful. 

Treatment of Fractures through the Tubercles (Extracapsular) ; Non- 
impacted and Impacted. — In these cases, also, the fragments being 
seldom displaced, very little, if any, mechanical treatment is demanded. 
A sling is all that is usually required. If, however, on account of dis- 
placement of the fragment, a splint is thought necessary, it must be 
applied in the manner hereafter to be directed in cases of fractures of. the 
surgical neck. If impaction, with shortening, exists, the same remarks 
are applicable here as in intracapsular impacted fractures, namely, that 
we ought not to rotate the limb much, nor violently, in order to discover 
crepitus, nor make extension with the view of overcoming the shorten- 
ing, since the fragments unite more promptly and certainly when the 
impaction remains, and its continuance in no way damages the usefulness 
of the limb. 

Treatment of Longitudinal Fracture of the Head and Neck, or of a 
Separation of the Greater Tubercle. — In the only instance which I have 
recognized as a fracture of the greater tubercle, and already referred to, 
the displacement was moderate, and could not be overcome either by 
change of position or by pressure with extension. The patient was, 
therefore, merely laid upon his back in bed. No dressings of any kind 
were employed, and the fragments seemed to unite promptly, and with 
no increase in the displacement. If the displacement is originally more 
considerable, attempts ought to be made to reduce the fragments, by 
extension and abduction of the arm, with direct pressure ; yet they will 
not generally prove completely successful, nor will it be found easy to 
retain them when reduced. 

Treatment of Fractures of the Surgical Neck, including Separations 
at the Epiphysis. — We have already considered the value of Moore's 
method of reduction in cases of incomplete epiphyseal separations of the 
upper end of the humerus ; but the reduction having been accomplished, 
I see no reason to suppose that the indications of treatment can essen- 



224 FRACTURES OF THE HUMERUS. 

tially vary in separations at the epiphysis from those in true fractures 
through any part of the surgical neck, since the relative action of the 
muscles remains the same, and the direction of the displacement is gen- 
erally the same. My remarks, therefore, upon this point may be con- 
sidered as equally applicable to fractures and epiphysary separations. In 
a considerable proportion of these cases not much displacement of either 
fragment takes place, and consequently we have only to apply such 
moderate retentive means as will insure quiet. Indeed, under such cir- 
cumstances we might not hesitate to adopt the posture treatment prac- 
tised by Dupuytren in two cases, both of which terminated favorably. 
The treatment consisted in placing the arm, semi-flexed, on a pillow, the 
pillow being arranged so as to form a pyramid, the summit of which was 
lodged in the axilla, while the elbow was secured to the side of the body 
by a bandage. 1 

Unhappily, however, as we have seen, this condition is not always 
present ; the most frequent form of displacement being that in which the 
lower fragment is drawn upward and inward, or toward the coracoid pro- 
cess. In such cases it will require, often, no little perseverance and skill 
to effect reduction, if it is not found to be actually impossible, and still 
more to retain the bones in place when once reduced Indeed, it is 
proper to say that a complete reduction is seldom accomplished and per- 
manently maintained, owing, probably, to the advantageous action of 
the muscles which tend to produce the displacement, and in part also to 
the difficulty of applying any apparatus or dressing which shall act 
efficiently upon the fragments. 

Sir Astley Cooper recommends for this accident a couple of splints, to be 
placed one in front of and one behind the shoulder, an axillary pad, a clavicular 
bandage, and a sling ; the sling being made to suspend only the wrist, and not 
the elbow, since he had observed that when the elbow was lifted the upper end 
of the shaft was inclined to fall forward. 

Mr. Tyrrel informed Mr. Cooper that in a similar case he had found the bone 
best maintained in its natural position by its being raised and supported at right 
angles with the side, by a rectangular splint, a part of which rested against the 
side, while the arm reposed upon the other part ; and until he had made use of 
this plan, he could not succeed in removing the deformity, or in keeping the 
bone in its place. 

The following is the plan which I have myself generally preferred : 
Two splints are prepared, made of felt, gutta-percha, gum-shellac 
cloth, or leather. The two latter are the most economical, generally 
most easily obtained, and answer the purpose as well as either of the 
others. The leather to be employed should be sole leather, of medium 
thickness, and hemlock-tanned. The " long " splint must be long enough 
to extend from the top of the acromion process to a point just above the 
external condyle. The form of the leather splint, before it is moulded, 
is represented in the accompanying woodcut, Fig. 108. It is then to be 
bevelled or thinned along its edges by shaving a thin ribbon from the 
margins on the side which is to be laid against the arm ; a few holes are 
to be made with a brad-awl on the margins of the V-shaped section at 
the upper end. Having soaked the splint in water a few minutes, or 

1 Dupuytren on Bones, Sydenham edition, p. 99. 



FRACTURES THROUGH THE SURGICAL XECK 



225 



until it is rendered slightly flexible, it is rolled up from its two sides 
until it has the natural curve of the circumference of the arm. If it is 
made too wet it will yield under the pressure of the bandages, and this 
is not desirable. It ought to be straight, or nearly so, in its longitudinal 
axis, except at the top, where it embraces the end of the shoulder ; and 



Fig. 108. 




Fig. 109. 




Fig. 110. 



Plan of author's long 
leather arm-splint. 



Long leather splint closed 
at top, and in shape. 



Short splint. 



it should be inflexible when applied, the splint touching the arm firmly 
only over the head and tuberosities, and along the lower portion of the 
humerus. The V-shaped section at the top of the splint is then closed 
with strong linen, or shoemaker's thread ; and in order to give it a more 
regular curve, and to render it smooth, it may be hammered. 

Some of the splints which surgeons prepare, in imitation of this general plan, 
extend too far upon the shoulder, and are liable to be disturbed in the motions 
of the neck or of the arm. It is only necessary that the splint should embrace 
the shoulder sufficiently to prevent its sliding: down. The splint will now be 
completed by inclosing it in a loose flannel sack, stitched on the outside. If the 
arm is swollen and tender, or the skin very delicate, a thin sheet of cotton 
wadding should be laid between the cover and splint. 

The ••short"' splint made of leather, or gum-shellac cloth — binders' 
board will answer equally well — carefully trimmed, and covered with 
flannel cloth, must have sufficient length to extend from the free margin 
of the axilla to the internal condyle, taking care that it shall not touch 
either. The purpose of this splint is not to support the fragments, for it 
is apparent that it cannot extend so high, even, as the point of fracture; 
but it is solely to protect the delicate skin beneath the arm from the 
bandages, which are apt to form cords and cause excoriations. In this 
point of view it is of great importance, and cannot properly be omitted. 
The splints being laid upon the arm. and while extension and counter- 
extension are maintained by assistants, for the purpose of restoring the 
fragments to position if possible, the surgeon will apply a roller, in- 
closing the splints, from the elbow to the axillary margins. This roller 
must be carefully stitched to the covers of both splints. A second roller 

15 



226 



FRACTURES OF THE HUMERUS. 



is then carried from the top of the long splint to the opposite axilla, and 
by several successive turns the upper end of the splint and the shoulder 
are completely covered in. This is also to be made fast to the cover of 
the long splint, by stitches. Finally, a third roller is made to inclose 
both the body and the lower portion of the arm ; and the forearm is 
secured at a right angle with the arm by a sling, looped under the forearm. 
It is important that the sling shall not embrace the elbow, since it will, if 
thus applied, tend to displace the fragments and drive them past each other. 

The bandage or roller hitherto applied by surgeons to the hand and forearm, 
when dressing a broken humerus, is wholly unnecessary and often a source of 
annoyance. The roller inclosing the arm and splints will seldom give rise to 
serious congestion or swelling of the forearm and hand unless it is applied too 
tightly ; and when swelling does occur it will be promptly relieved by a few 
hours' or days' confinement in the horizontal position. The most serious objec- 
tion, however, to the roller applied to the hand and forearm, is not that it is 
unnecessary, but that it is, in most cases, injurious. It is exceedingly liable to 
become disarranged, especially if the patient is permitted to move the arm at 
the elbow-joint; and in most cases it will soon be found, by its unequal pressure, 
to cause those congestions and swellings which it was designed to prevent. 
Perhaps it will be sufficient for me to say that for many years I have rejected 
this bandage altogether in all fractures of the humerus, and that no harm has 
ever come of the practice. 

It will be readily seen that the first roller performs the most important func- 
tion in this dressing. The long outer splint being firm and unyielding, and 
being supported above by the projection of the head of the humerus, the first 
roller draws the upper end of the lower fragment outward, and thus, as far as 
possible, accomplishes its readjustment. The upper fragment is always beyond 
our control. The second roller is not of much use, inasmuch as it soon becomes 
loose ; and in any event it can only hold the top of the splint a little more 

firmly against the head of the humerus. I occa- 
Fm. 111. sionally omit it. The third roller insures quietude 

to the arm, in the best position, namely, beside the 

body. 

When the patient is standing or sitting, the 
forearm needs to be suspended in the sling ; 
but when reclining, the forearm may, if the 
patient chooses, be extended. If the entire 
dressing is well stitched, it is not much liable 
to disarrangement, and may be worn two or 
three weeks at a time without removal ; but 
from time to time, as the swelling subsides or 
the muscles atrophy, the bandages may need 
to be tightened by overstitching, or by sup- 
plementary rollers. 

I have been thus minute in my description of 
this dressing, because its value depends upon the 
care with which the details are carried out ; and 
because, essentially, the same dressing is used by 
me in all fractures of the humerus occurring 
through its upper or middle thirds; moreover, I 

do not wish to be held responsible, in any case, for bad results when dressings 

are applied in an imperfect or slovenly manner. 

[Erichsen describes a very useful dressing, consisting of a pad on the inner 

side of the arm, and a leather splint on the outside and over the shoulder ; the 

hand being supported in a sling, while the elbow remains dependent.] 




Apparatus for fracture of the 
neck of the humerus. (Erich- 
sen.) 



SHAFT BELOW THE SURGICAL NECK. 227 

If union takes place without overlapping, of course the arm is not maimed by 
the fracture ; but even when the union occurs with considerable overlapping, 
the usefulness of the arm is seldom impaired. In case the functions of the arm 
are seriously impaired in consequence of the displacement of the fragments, and 
many months or years have elapsed without any improvement, a result which, 
to say the least, is very uncommon, the surgeon might consider the propriety of 
surgical interference, after the method of Lindner, who cut down and reduced 
the fracture, with the result of only a partial reduction, with fibrous union, 
but it is added, that the functions of the arm were restored. It is my opinion, 
however, that the discreet surgeon will not find satisfactory reasons for such a 
procedure. 1 

§ 5. Shaft, below the Surgical Neck and above the Base of the Condyles. 

Causes. — In a record of 36 cases in which the cause of the fracture 
is stated, I find this portion of the shaft broken from direct violence 
21 times ; from indirect blows, the concussion being received upon the 
elbow, 9 times ; twice it was a consequence of syphilis, once it occurred 
during birth, and three times in the same patient it has been broken from 
muscular action alone, each consecutive fracture occurring at a different 
point. The records of surgery furnish many examples of fracture of 
the shaft of the humerus from muscular action, as in throwing a stone 
or snowball. 

The most singular examples are those in which the bone has been broken in 
a trial of strength between two persons, by grasping the hands palm to palm, 
with the elbows resting upon a table, and twisting, when the humerus has 
suddenly given way a little above the condyles. This practice is called by the 
French " tourner poignet,'' the game of turning wrists. I have seen one case of 
this kind, which was under the care of Dr. Winne, and Malgaigne has collected 
five other similar cases, two of which were reported by Lonsdale. In X' Union 
Medicate is reported an example in which the fracture occurred on a level with 
the insertion of the deltoid, a little below the insertion of the pectoralis major 
and latissimus dorsi. The fracture seemed to be nearly transverse. 2 

[Lebeuf, 3 of Houma, La., reports a case of double fracture of the same hume- 
rus in throwing a ball ; both were in the shaft.] 

The example of fracture during birth, to which I have referred, occurred in a 
healthy female child, whose parents were also healthy. The mother was in 
labor six or eight hours, but the labor was not severe. She was attended by a 
midwife, but does not know whether violence was employed or not. Dr. Lock- 
wood, of Buffalo, was called on the third day, and found the arm broken a little 
below its middle, and moving as freely as it did at the elbow-joint; he applied 
lateral splints with bandages, etc. I saw the child with Dr. Lockwood on the 
seventeenth day after its birth. There was then a perfect ferrule of ensheathing 
callus surrounding the fragments, and which, owing to the softness of the flesh, 
could be easily detected and defined. The fragments had been firm at least 
three or four days. Nearly a year after, I again examined the arm, and could 
not discover any traces of the accident. 

Dr. Lowenhardt has also reported a case in which the evidence was conclusive 
that the fracture was caused solely by the contractions of the uterus, which 
forced the arm against the pubes ; the arm being heard distinctly to snap when 
it was passing this point and while the hands of the accoucheur were not aiding 
in the delivery. In this case the humerus was broken in its upper third. 4 

1 Lindner, Centralblatt f iir Chir., 1881, April 16. 

2 Anier. Med. Times, vol. iv. p. 153. 

3 X. 0. Med. and Surg. Journ., Feb. 1888. 

* Lowenhardt, American Journal of the Medical Sciences, January, 1841, p. 250, from 
Medicin. Zeit., Mai 6, 1840. 



228 FRACTURES OF THE HUMERUS. 

Dr. N. Fanning, of Catskill,N. Y., has reported to me the following as having 
occurred in his own practice : " Mrs. H. was delivered, after a short and not 
severe labor, of a full-grown and healthy male child. The mother was well 
formed, with ample pelvis. The labor was natural, and the presentation the 
most iavorable, the occiput corresponding to the left acetabulum; but imme- 
diately after the delivery of the head, a hand and a portion of the forearm of 
the child were felt above the pubes. The shoulders and body were delivered 
very quickly after the head, and during a single pain. Just as the right shoul- 
der of the child was passing under the arch of the pubes, I heard a snap, not 
unlike that caused by the breaking of a pipe-stem, which I soon found, as I 
suspected, to be caused by the fracture of the right os humeri of the child in its 
upper third." The bone united with some deformity. , Dr. Fanning is of the 
opinion that, in this case, the contraction of the uterus, occurring while the arm 
of the child occupied some unusual position, was the cause of the fracture. 

Seat and Direction of the Fracture. — The seat of the fracture is 
more often below than above the middle of the bone ; thus, I have found 
the fracture fourteen times near the middle, and the same number of 
times below the middle third, but only seven times above the middle 
third. The observations of Norris, who found four fractures of the shaft 
above the middle, and nine below, correspond with my own ; l but M. 
Gu6retin, in the same number of fractures, found nine above the middle 
and four below. 2 The line of fracture is generally oblique, but more 
often transverse than in fractures of the clavicle, femur, or tibia. 

Displacement. — The direction of the displacement depends, no doubt, 
sometimes upon the precise point of the fracture and upon the action of 
the muscles operating upon the two fragments ; thus, if the fracture takes 
place just above the insertion of the deltoid, the lower fragment is liable 
to be drawn upward and outward, in the direction of its fibres, while the 
upper fragment is carried toward the origin of the pectoralis major, etc. ; 
but, in a great majority of cases, the influence of these muscles is more 
than counterbalanced by the direction of the force, and by the direction 
of the fracture. Practically, therefore, it is seldom of much importance 
to determine the exact point of fracture, as to whether it is just above or 
below the insertion of a particular muscle ; nor, indeed, is it generally 
very easy to ascertain this point with much precision. 

The amount of displacement varies considerably in different persons 
and in fractures at different points, but it will average about three-quar- 
ters of an inch. When the fracture is produced by muscular action alone, 
it is generally transverse, and displacement seldom occurs. Such was 
the fact in every instance w T here my own patient broke the arm three 
times consecutively at different points ; and union was speedily accom- 
plished, and with no deformity. 

Dupuytren, however, saw a case which constituted an exception to this gen- 
eral rule. The fragments became completely separated, and were so movable 
that union could not be effected, and he was compelled, after three months, to 
resort to resection. 

The average shortening after these fractures, exclusive of those which 
do not shorten at all, seems to be about half an inch ; but a considerable 

1 Norris, Amer. Journ. Med. Sci., Jan. 1842, vol. xix. p. 28. 

2 Fresse Medicale, vol. i. p. 45. 



SHAFT BELOW THE SURGICAL NECK. 229 

number are never displaced, as the fractures are so nearly transverse 
that they are easily reduced and maintained in place, and consequently 
the total average of shortening is probably less than half an inch ; in a 
few cases it is much greater. Practically, the shortening is a matter of 
no importance. 

Prognosis. — I have met with a number of examples of delayed and of 
fibrous union of this bone after a fracture. 

In the first example of a complete failure the fracture was in the lower third 
of the shaft, oblique and compound, and no union had taken place at the end of 
five months. The man was intemperate, but in pretty good health. 1 In the 
second case, the fracture had occurred a little below the middle of the bone, 
and it was simple. Five months after the accident this patient consulted me, 
when I found the elbow ankylosed, and the forearm was fixed at a right angle. 2 
In the third case, a lad, five years of age, received a fracture about three or 
four inches above the elbow-joint, by the passage across the limb of a heavy 
army wagon. The arm was dressed with splints, and in about five weeks several 
fragments of necrosed bone were removed by Dr. Pope, of St. Louis, and the 
splints were again applied. Ten months from the date of the injury, Dr. Brin- 
ton, of Philadelphia, operated by perforation, and reapplied splints. When the 
splints were removed, the limb was straight and apparently firm, but the bond 
of union gradually gave way, and when he came under my charge, more than 
two years after the accident, the arm was bent at an angle of 45°, and the union 
was fibrous only. Under my advice all restraint and dressings were removed, 
and he was sent into the country to improve his general health, with the under- 
standing that I would operate at some future day. Subsequently, I resected the 
bone at the seat of fracture, securing the fragments with wire, and supporting 
the arm with a gutta-percha splint. The result was a perfect bony union. 
The fourth case is briefly as follows: C. C, aet. about thirty-five, broke his 
right arm a little below its middle ; the fragments united only by fibrous tissue. 
Five months after, I incised to the bone, and with an ordinary steel gimlet trans- 
fixed the overlapping fragments. Splints were then applied. The gimlet was 
permitted to remain six weeks, during which time it became quite loose, and an 
abscess formed below the wound. At the end of this time the bond of union 
was quite firm, but the splints were continued six weeks longer. The union 
remains sound, the humerus is straight, and the usefulness of his arm perfect. 
In a fifth case, that of F. H. F., set. twenty-one, the right arm was broken 
below its middle, a simple fracture; pasteboard and wooden angular splints 
were employed, but only a fibrous union took place. Eight months after the 
accident the fragments remained ununited, and overlapped one inch. 

Muhlenberg, in his tables of delayed union and ununited fractures of long 
bones, including 656 cases, has recorded 219 of the humerus : of 13 treated by 
manual friction, 4 were cured and 9 failed ; of 10 treated by mechanical appli- 
ances, 6 were cured, 3 relieved, and 1 failed ; of 42 treated by seton, 12 were 
cured, 24 failed, and 1 died ; of 13 treated by immobilization, 5 were cured, 6 
failed, and 1 died; of 83 treated by resection, 43 were cured, 31 failed, 6 were 
relieved, 2 died, and in 1 the result is unknown ; of 35 treated by drilling, 21 
were cured, 2 were relieved, and 11 failed. 

In a few cases the elbow has remained somewhat stiff a long time after 
the splints were removed ; and in one case which was brought to my 
notice complete freedom of motion was not restored at the end of fifteen 
years. Generally, however, the motions of the elbow-joint have been 
very soon restored after the removal of the splints and sling. Not un- 
frequently, fractures of the shaft of the humerus, and especially where 

1 Report on Deformities, etc., Case 33. 2 Ibid., Case 21. 



230 FRACTURES OF THE HUMERUS. 

they are occasioned by direct blows, are followed by great swelling, and 
sometimes by abscesses. 

In one instance, the fracture having taken place within the insertion of the 
deltoid muscle, the sharp extremity of the lower fragment was made to penetrate 
the flesh, causing an abscess, and finally tetanus, of which my patient soon died. 
Dr. Lee writes me that a simple fracture of the lower third of the shaft, occur- 
ring in a child six years old, terminated in gangrene, and demanded amputation. 
Two other similar cases have been reported to me. In all of these cases a ques- 
tion arose as to the causes of the gangrene ; but the practice of the surgeons was 
sustained by the courts. 

P. F., set. twenty-one, was admitted to Bellevue, with a fracture of the left 
humerus, near its middle. The fracture was caused by a fall from a wagon on 
the same day. My splint was applied, and it was continued four weeks, when 
the fragments were found united, but he was discovered to have paralysis of the 
extensor muscles of the left hand and fingers. Two or three months later their 
condition had much improved. The arm was perfectly straight. The bandage 
was never tight, and the cause of the paralysis was unexplained. 

Muhlenberg, in his tables of united fractures, has recorded 219 of the hume- 
rus, in a total of 656 of all of the long bones. 

The following remarks of Malgaigne are too pertinent to be omitted in this 
connection: "When there is great obliquity, with overlapping, or a fracture 
with splintering, or a multiple fracture, a certain amount of deformity is inevit- 
able, and the formation of callus demands one or two weeks more. With the 
inflammation comes also the danger of suppuration, and later, a rigidity of the 
articulations difficult to dissipate. In short, we must not forget that of all frac- 
tures, those of the humerus are most liable to fail of consolidation." 

On the other hand, we shall find, in the case of this bone, as in all others, 
some remarkable exceptions, where, although the fracture may be compound, 
and badly comminuted, yet the limb has been saved and made useful. 

[Erichsen notices, as a complication, injury of the musculo-spinal nerve when 
the fracture is at the point where this nerve winds around the shaft; also, injury 
of the posterior branch (interosseous) when the fracture is lower down. When 

the main trunk is involved, all the mus- 
F TG . ii2. cles supplied by it are paralyzed, supina- 

tion is imperfect, and extension of the 
hand and fingers is entirely lost; the 
forearm becomes pronated and the hand 
and fingers passively flaccid, so that a 
form of wrist-drop ensues (Fig. 112). 
Though the extensors of the wrist and 
fingers have become paralyzed, yet when 
the fingers are flexed (a), they can be ex- 
tended rapidly and with some force at the 
interphalangeal articulations (6). If the 
posterior interosseous nerve only is. in- 
volved, the loss of supination and exten- 
sion is necessarily not so complete as 
Paralysis of hand ( Wrist- drop , after frac- wheQ ^ whde ^ . g .^^ It - 

ture of humerus. (Er.chsen). important to recognize these forms of 

paralysis caused by the injury or by the 
pressure of callus, as they are liable to be attributed to the dressings. The 
treatment of paralysis from injury must be directed, first, to relief to the 
inflammation, and, second, to efforts to secure motion by massage. The false 
position of the hand and fingers may be overcome by apparatus, as splints. 
If the paralysis is due to encroachment of callus, this may be removed by 
operation.] 

[Another sequel of fracture of the humerus has been noticed by Bryant, of 
London, viz., arrest of growth. This condition is liable to be attributed to the 
treatment. In the two cases which he mentions one is alleged to be due to an 




SHAFT BELOW THE SURGICAL NECK. 



231 



injury to the nutrient artery, and the other to injury to the epiphyseal cartilage 
at the upper part of the shaft.] 



\ i 



Right humerus 



Fig. 113. 





Arrest of growth in the humerus after 
fracture in early life. (Bryant.) 



Left humerus. 



Treatment. — In the treatment of fractures of that portion of the shaft 
of the humerus now under consideration, we shall do best to adopt essen- 
tially the same plan which I have recommended for fractures of the 
surgical neck. In proportion as the fracture occurs at a lower point of 
the humerus, however, will it be necessary to extend the long splint 
downward, in the direction of the elbow ; so that, while in fractures of 
the surgical neck and upper half of the shaft it may not be necessary to 
extend the splint quite so low as the external condyle, in the case of 
fractures in the lower half of the shaft it will be necessary to include the 
condyles with the splints, and sometimes it may be necessary to employ 
the gutta-percha angular splint, which will be recommended hereafter in 
fractures involving the elbow-joint. It is in these latter cases, also, that 
we shall find, sometimes, the plaster-of- Paris dressing, including the 
forearm, arm, and shoulder, giving the most satisfactory results ; never 
neglecting, however, when using this or any other form of immovable 
dressing, to observe the condition of the arm frequently as to the swell- 
ing or shrinkage. Whenever the splints are made to touch or include the 
condyles, very great care must be taken to protect them from pressure. 

Other surgeons have sought to make permanent extension in these and certain 
other fractures of the humerus, by various contrivances. Mr. Lonsdale con- 
structed an instrument which might be lengthened or shortened to suit the case. 
Dr. Martin, of Boston, has invented a splint for the purpose of making exten- 
sion in fractures of the humerus, the counter-extension being made by adhesive 
plasters from the side of the chest. The apparatus is elongated by a ratchet 
operating upon two steel bars, which are thus made to move upon each other. 
In my opinion, and in the opinion of nearly all practical surgeons who have 
written upon this subject, it is impossible by these or any other similar contriv- 



232 



FRACTURES OF THE HUMERUS. 



Fig. 114. 



ances to make extension in fractures of the humerus. The axilla can never be 
made a proper point of support for permanent counter-extension. 

The late Dr. E. A. Clark, of the St. Louis City Hospital, proposed to accom- 
plish the extension, in fractures of the head and surgical neck, by suspending a 

weight from the elbow. (Fig. 114.) When 
the patient is in the recumbent posture, the 
weight must be suspended over a pulley. No 
doubt this is the only method by which really 
effective extension can ever be made in frac- 
tures of the humerus. There may be, per- 
haps, examples of fractures of the neck of the 
humerus in which the fragments overlap per- 
sistently, where it will be proper to resort to 
this novel expedient. When fractures occur 
above the deltoid, the overlapping is often 
excessive, and there is not much danger of 
their being forcibly separated by the exten- 
sion ; but in fractures below this, Clark's 
method might possibly expose to the danger 
of separation and non-union of the fragments, 
but it will be observed that this was the class 
of cases successfully treated. In the case of 
fractures of the neck, no splints are advised 
by Dr. Clark ; yet, as a means of holding the 
lower fragment out, a single outside splint 
might be useful. 

I have seen a case of compound fracture of 
the humerus treated by Dr. Stephen Smith, 
at Bellevue, in this manner, while the patient 
was confined to the bed, with the most satis- 
factory results; and recently, in a case of 
fracture of the humerus a little above the 
middle, complicated with other severe inju- 
ries, which eventually proved fatal, this 
method of extension was employed success- 
fully by me, to prevent the violent spasmodic 
contractions of the muscles. In this case the 
arm and forearm were kept extended, the 
adhesive plaster extension strips being made 
fast to the hand and forearm, and the pulley and weight being arranged at the 
foot of the bed. 




Clark's extension in fractures of the 
neck of the humerus. 



In reference to those forms of apparatus which are intended to press 
upon the axillary margins, it ought to be stated here, since we have 
omitted to speak of it in connection with fractures of the surgical neck, 
that in all fractures of the upper half or third of the humerus, including 
fractures of the surgical neck, they are not only useless, but they actually 
tend to defeat their own purpose. They are intended to replace the 
fragments ; but by their pressure upon the pectoralis major and latissimus 
dorsi, which compose the free margins of the axillary space, they must 
inevitably cause the separation of the fragments. 

Fig. 115. 



Erichsen's sole-leather splint. 



[The application of a narrow pad to the internal surface of the humerus at its 
upper part is useful in supporting the fragments, and to prevent their falling 



SHAFT BELOW THE SURGICAL NECK. 233 

inward ; the pad should not be so broad as to press on the latissimus and pec- 
toralis major. Erichsen uses in some cases a piece of sole-leather, two feet long 
by six inches broad, bent in the middle and applied so that oue half is length- 
wise against the chest and the other against the inside of the arm, the angle 
being in the axilla (Fig. 115).] 

Malgaigne, when speaking of the apparatus of Lonsdale, remarks: "But the 
surgeon should never lose sight of the fact that permanent extension is a resource 
always dangerous, often useless, and which demands in its application much 
caution and watchfulness." 

The following example will illustrate the practical difficulty of employing 
permanent extension in fractures of the humerus : A laborer, aged thirty, was 
admitted into the Buffalo Hospital of the Sisters of Charity with a simple oblique 
fracture of the humerus, which had occurred three days before. The fracture was 
situated within the insertion of the deltoid, and having been produced by the roll- 
ing of a log upon the arm, the whole limb was much swollen. The night following 
his admission, in a fit of delirium tremens, he removed all of the dressings. In the 
morning I found the fragments displaced and the muscles contracting violently. 
The ordinary dressings were applied, and continued until the fifth day, when, 
as the delirium had not ceased, and the muscles continued to contract with great 
violence, it was determined to attempt permanent extension. For this purpose 
we lifted the elbow upward and outward, to relax the deltoid, and then, having 
made extension w T ith the forearm placed at a right angle with the arm, we fitted 
carefully a large gutta-percha splint to the forearm, arm, axilla, and side, in 
such a manner that when the splint was secured to these several parts, the arm 
could not fall to the side of the body completely, and in proportion as it did fall 
downward, it would make extension upon the arm. This splint was well padded, 
and secured in place by rollers. On the sixth day the delirium had ceased, and 
never returned. The dressings were well in place, and seemed to accomplish 
the indication we had in view; but, on the seventh day, although he had kept 
very quiet, everything was disarranged, and the whole had to be readjusted. 
On the eighth and ninth days the same thing occurred. During this time we 
varied the dressings, position, etc., each day, to meet, if possible, the difficulties ; 
but it was at length deemed unwise to pursue the attempt any farther, and we 
returned to the use of the ordinary splints, laying the arm against the side of the 
body. The union was finally completed without either overlapping or angular 
displacement. I have no doubt now that we would have done much better if we 
had resorted to extension, as practised by Dr. Clark. 

Something may always be accomplished when the patient is walking about, 
by allowing the elbow to escape from the sling, so that its weight shall make 
constant traction upon the lower fragment; and the plan which I suggested 
some years since, of treating certain cases of delayed union of the humerus, 
namely, extending the arm at full length by the side of the body, so that the 
lower fragment shall receive the whole weight of the forearm and hand, might 
occasionally prove valuable in recent fractures w r here the tendency to override 
was very great. 

Delayed Union. — Non-union results more frequently after fractures of 
the shaft of the humerus, than after fractures of the shaft of any other 
bone. 

Comparing the humerus with the femur, between which, above all others, the 
circumstances of form, situation, etc., are more nearly parallel, and in both of 
which non-union is said to be relatively frequent, I find that of forty-nine frac- 
tures of the humerus, four occurred through the surgical neck, twelve through 
the condyles, and twenty-nine through the shaft. In one of the twenty-nine 
the patient survived the accident only a few days. In four of the remaining 
twenty-eight union had not occurred after the lapse of six months, and in many 
more it was delayed beyond the usual time. Two of the four were simple frac- 
tures, and occurred near the middle of the humerus; the third was compound, 
and occurred near the middle also; the fourth was compound, and occurred 
near the condyles. This analysis supplies us, therefore, with four cases of non- 
union, from a table of twenty-eight cases of fracture through the shaft. 



234 FRACTURES OF THE HUMERUS. 

Of eighty-seven fractures of the femur, twenty occurred through the neck, 
one through the trochanter major, and one through the condyles. The remain- 
ing sixty-five occurred through the shaft, and generally near the middle, and 
not in one case was the union delayed beyond six months. To make the com- 
parison more complete, I must add that of the twenty-eight fractures of the 
shaft of the humerus, six were compound ; and of the sixty-five fractures of the 
shaft of the femur, six were either compound, comminuted, or both compound 
and comminuted. The six compound fractures of the shaft of the humerus 
furnished two cases of non-union. The six cases of either compound or com- 
minuted or compound and comminuted fractures of the femur, furnished no 
case of non-union. 

The * following seems to me to be the true explanation of these 
facts : It is the universal practice, so far as I know, in dressing fractures 
of the humerus, to place the forearm at a right angle with the arm. 
Within a few days, and generally, I think, within a few hours, after the 
arm and forearm are placed in this position, a rigidity of the muscles and 
other structures has ensued, and to such a degree that if the splints and 
sling are completely removed, the elbow will remain flexed and firm; 
nor will it be easy to straighten it. A temporary false ankylosis has 
occurred, and instead of motion at the elbow-joint, when the forearm is 
attempted to be straightened upon the arm, there is only motion at the 
seat of fracture. It will thus happen that every upward and downward 
movement of the forearm will inflict motion upon the fracture ; and inas- 
much as the elbow has become the pivot, the motion at the upper end of 
the lower fragment will be the greater in proportion to the distance of 
the fracture from the elbow-joint. 

No doubt it is intended that the dressings shall prevent all motion of 
the forearm upon the arm ; but I fear that they cannot always be made 
to do this. I believe it is never done when the dressing is made without 
angular splints, nor is it by any means certain that it will be accomplished 
when such splints are used. The weight of the forearm is such, w T hen 
placed at a right angle with the arm, and encumbered with splints and 
bandages, that even when supported by a sling, it settles heavily for- 
ward, and compels the arm-dressings to loosen themselves from the arm 
in front of the point of fracture, and to indent themselves in the skin 
and flesh behind. By these means the upper end of the lower fragment 
is tilted forward. If the forearm should continue to drag upon the sling, 
nothing but a permanent forward displacement would probably result. 
The bones might unite, yet with a deformity. 

But the weight of the forearm under these circumstances is not uni- 
form, nor do I see how it can be made so. It is to the sling that we 
must trust mainly to accomplish this important indication. But we 
have all noticed that the tension or relaxation of the sling depends upon 
the attitude of the body, whether standing or sitting ; upon the erection 
or inclination of the head ; upon the motions of the shoulders ; and in 
no inconsiderable degree upon the actions of respiration. Nor does the 
patient himself cease to add to these conditions by lifting the forearm with 
his opposite hand whenever provoked to it by a sense of fatigue. 

This difficulty of maintaining quiet apposition of the fragments while 
the arm is in this position, at whatever point it may be broken, becomes 
more and more serious as we depart from the elbow-joint, and would be 



SHAFT BELOW THE SURGICAL NECK. 235 

at its maximum at the upper end of the humerus, were it not that here 
a mass of muscles, investing and adhering to the bone, in some measure 
obviates the difficulty. Its true maximum is, therefore, near the middle, 
where there is less muscular investment, and where, on the one hand, 
the fracture is sufficiently remote from the pivot or fulcrum to have the 
motion of the upper end of the lower fragment multiplied through a long 
arm, while, on the other hand, it is sufficiently near the armpit and 
shoulder to prevent the upper portion of the splint and arm-dressings 
from obtaining a secure grasp upon the lower end of the upper fragment. 

It must not be overlooked that the motion of which we speak belongs 
exclusively to the lower fragment, and that it is always in the same plane 
forward and backward, but especially that it is not a motion upon the 
fracture as upon a pivot, but a motion of one fragment to and from its 
fellow. This circumstance I regard as important to a right appreciation 
of the difficulty. Motion alone, I am fully convinced, does not so often 
prevent union as surgeons have generally believed. It is exceedingly 
rare to see a case of non-union of the clavicle. Of forty-seven cases of 
fracture of the clavicle which have come under my observation, and in 
by far the greater proportion of which considerable overlapping and con- 
sequent deformity ensued, only one has resulted in non-union, and in this 
instance no treatment whatever was practised, but from the time of the 
accident the patient continued to labor in the fields, and hold the plough 
as if nothing had occurred. I have, therefore, seen no case of non- 
union of the clavicle where a surgeon has treated the accident. Indeed, 
what is most pertinent and remarkable, its union is more speedy, usually, 
than that of any other bone in the body of the same size. Yet to pre- 
vent motion of the fragments in a case of fractured clavicle with com- 
plete separation and displacement, except where the fragment is near one 
of the extremities of the bone, I have always found wholly impracticable. 
Whatever bandage or apparatus has been applied, I have still seen always 
that the fragments would move freely upon each other at each act of 
inspiration and expiration, and at almost every motion of the head, body, 
or upper extremities. 

From this and many similar facts I have been led to suspect, for 
a long time, that motion has had less to do with non-union than was 
generally believed. I find, however, no difficulty in reconciling this 
suspicion with my doctrine in reference to the case in question ; and it is 
precisely because, as I have already explained, the motion, in case of a 
fractured humerus, dressed in the usual manner, is peculiar. In a frac- 
ture of the clavicle through its middle third (its usual situation), the 
motion is upon the point of the fracture as upon a pivot ; although, 
therefore, the motion is almost incessant, it does not essentially, if at all, 
disturb the adhesive process. The same is true in nearly all other frac- 
tures. The fragments move only upon themselves, and not to and from 
each other. I know of no complete exception but in the case now under 
consideration. 

Aside from any speculation, the facts are easily verified by a per- 
sonal examination of the patients during the first or second week of 
treatment, or at any time before union has occurred, both in fractures 
of the humerus and clavicle. The latter is always sufficiently exposed 



236 



FRACTURES OF THE HUMERUS, 



Fig. 116. 



to permit you to see what occurs; and as soon as the swelling has a little 
subsided in the former case, we will have no difficulty in feeling the 
motion outside of the dressings, or, perhaps, in introducing the finger 
under the dressings sufficiently far to reach the point of fracture. 

I know of no other circumstance or condition in which this bone is 
peculiar, and which, therefore, might be invoked as an explanation. 
Overlapping of the bones, the cause assigned by some writers, is not 
sufficient, since it is not peculiar. The same occurs much oftener, and 
to a much greater extent, in fractures of the femur, and equally as often 
in fractures of the clavicle, yet in neither case are these results so fre- 
quent. Nor can it be due to the action of the deltoid muscle, or of any 
other particular muscles about the arm, whether the fracture be below or 
above their insertions, since similar muscles, with similar attachments, 
on the femur and on the clavicle, tending always powerfully to the sepa- 
ration of the fragments, occasion deformit}^, but they seldon prevent 
union. If I am correct in my views, we shall be able sometimes to con- 
summate union of a fractured humerus where it is delayed, by straight- 
ening the forearm upon the arm, and con- 
fining them to this position. A straight 
splint, extending from the top of the 
shoulder to the hand, constructed from 
some firm material, and made fast with 
rollers, will secure the requisite immobility 
to the fracture. The weight of the fore- 
arm and hand will only tend to keep the 
fragments in place, and if the splint and 
bandages are sufficiently tight, the motion 
occasioned by swinging the hand and fore- 
arm will be conveyed almost entirely to 
the shoulder-joint. Very little motion, 
indeed, can in this posture be communi- 
cated to the fragments, and what little is 
thus communicated is a motion, as experi- 
ence has elsewhere shown, not disturbing 
or pernicious, but a motion only upon the 
ends of the fragments, as upon a pivot. 

I do not fail to notice that this position 
has serious objections, and that it is liable 
to inconveniences which must always, 
probably, prevent its being adopted as the 
usual plan of treatment for fractured arms. It is more inconvenient to 
get up and lie down, or even to sit down, in this position of the arm, and 
the hand is liable to swell. But I shall not be surprised to learn that 
experience will prove these objections to have less weight than we are 
now disposed to give them. 

Measurement.— It may be well to indicate in this place by what 
method we shall best insure an accurate measurement of the arm or 
forearm. 

In either case, the point from which the measurement can be most satisfac- 
torily made above, is the posterior and inferior edge of the acromion process, at 




Fracture at the base of the condyh 
(From Gray.) 



BASE OF THE CONDYLES, 



237 



the most salient point of this margin, about opposite the scapuloclavicular 
articulation. If the arm can be straightened, the extremity of either of the 
ringers can be used as the lower fixed point. If the arm cannot be straightened, 
we may use as the lower point either condyle, or the point of the elbow. In 
order to get the point of the elbow accurately, the hands should be clasped in 
front of the body ; and as the elbows are pressed back, a rule may be laid 
beneath, and the measurements made from the upper surface of the rule. 



§ 6. Base of the Condyles. 

Syn. — Supra-condyloid Fractures of the Humerus. — Malgaigne. 

Of 18 fractures at this point, 12 occurred in children under ten years 
of age, the youngest being two years old. In 11 cases the fracture had 
been produced by a fall, and it is presumed that the blow was received 
upon the elbow ; in the remaining six cases the cause is not stated. This 
fracture is, therefore, generally the result of an indirect blow, inflicted 
upon the extremity of the elbow ; in a few examples it has been produced 
by a blow received directly upon the point of fracture, as by the kick of 
a horse, etc., but I have never, save in a single instance, been able to 
trace it to a fall upon the hand. Dr. Shearer, U. S. A., has reported a 
case also, which seems to have occurred in the same manner. 1 



Fig. 11' 



Fig. 118. 



Fig. 119. 




Dr. Beeve's case of Dr. Lange's case of separation of lower 

separation of the lower epiphysis, and detachment of epicon- 
Lower epiphysis. epiphysis. dyles. 



Direction of the Fracture, Displacement, and Symptoms. — This frac- 
ture is generally oblique, and its line of direction upward and backward ; 



1 M. M. Shearer, Act. Asst. Surgeon, U. S. A. Boston Journal of Chemistry, Feb. 1, 
1870. 



238 FRACTURES OF THE HUMERUS. 

in nine of the eleven cases where this point was determined such has been 
its apparent direction, and the lower fragment has been found drawn up 
behind the upper. Once I have found the lower fragment in front, and 
once on the outside of the upper. Three of the eighteen were compound 
comminuted fractures, this being a larger proportion of serious complica- 
tions than is usually found in connection with fractures of long bones. 

Separation of the Lower Epiphysis. — Surgical writers have occasion- 
ally spoken of this accident, and the late Dr. Watson, of New York, 
believed that he had seen one example in an infant not quite two years 
old. The limb had been violently wrenched by the mother, in attempt- 
ing to lift her. She was not seen by Dr. Watson until the fourth day, 
at which time the swelling was such that the diagnosis could not be 
easily made out; but on the ninth day "it was apparent that the shaft 
of the humerus had been separated from its cartilaginous expansion at 
the condyles, near the elbow." By the use of angular pasteboard splints 
the reduction was maintained, and the fragments became united after 
about four or six weeks. 1 

Dr. Reeve, of Dayton, Ohio, sent me a specimen of epiphyseal separation, 
which occurred in his practice in the year 1864. A girl, aged ten years, fell a 
few feet, striking, probably, upon her elbow. The fracture was compound, and 
union not having occurred at the end of three weeks, the condition of the arm 
rendered amputation necessary. In this case a small fragment of the shaft came 
away with the epiphysis. Drs. Little, Voss, Buck, 2 and Lange, 3 of this city, 
have each reported a similar case. Champion, 4 so long ago as 1818, described 
the case of a boy thirteen years old, in whom the epiphysis was torn off by the 
arm being caught in machinery ; amputation became necessary, and the boy got 
well. Mr. Hutchinson 5 describes one case also. In Champion's case, and in 
Dr. Reeve's, amputation became necessary. In Hutchinson's patient the upper 
fragment projected and was excised; the patient recovering with a stiff elbow. 
In Dr. Lange's patient the epiphysis was removed through the wound, and a 
portion of the shaft excised. He recovered with a useful arm. 

I wish to call attention to the frequency with which examples of epi- 
physeal separation in the case of this bone, and of other bones, have 
been followed by suppuration. This will be found to be especially the 
fact in separations of the trochanter major, of the lower end of the femur, 
and lower end of the tibia. I shall not attempt at present to offer an 
explanation. 

True Fractures at the Base of the Condyles. — The diagnosis of a 
fracture at the base of the condyles is attended with peculiar difficulties, 
and it has occasionally been mistaken for a dislocation of the radius and 
ulna backward. 

•Dupuytren says : " There is nothing so common as to see a fracture of the 
lower end of the humerus, immediately above the elbow-joint, mistaken for a 
dislocation backward ;" and he mentions three cases which have come under 
his own observation. I have found an opposite error, however, by far the most 
frequent, namely, a dislocation of both bones backward has been supposed to be 
a fracture. 

1 Watson, New York Journ. Med., Nov. 1853, p. 430, second series, vol. xi. 

2 Little, Voss, and Buck, New York Journ. Med., Nov. 1865, p. 133. 

3 Lange, N. Y. Surg. Soc, 1880. 

4 Champion, Journ Comp. Kend. des Sci. Med., t. 1, 1818, p. 323 ; Gurlt, op. cit., t. 1, 82. 

5 Hutchinson, Med. Times and Gaz., 1866, t. 1, p. 360. 



BASE OF THE CONDYLES. 239 

The sources of embarrassment are found in the proximity of the frac- 
ture to the joint, in the rapidity with which swelling occurs, and in the 
striking similarity of the symptoms which characterize the two accidents. 
The following are the signs of fracture: 

1. Preternatural mobility, which, owing to the rapidity of the swelling and 
the contraction of the muscles whose tendons are stretched over the projecting 
ends of the bones, is often soon lost, being succeeded, sometimes after a few 
hours, by a rigidity equal to that which is usually present in dislocations, or 
even greater. It is especially difficult to flex the arm, owing to the projection 
of the upper fragment into the bend of the elbow. 

2. Crepitus. This can usually be detected at any period if the arm is suf- 
ficiently extended, so as to bring the broken surfaces again into apposition. 

3. When the extension is sufficient, reduction is easily effected, and the 
natural length of the arm is restored ; but the limb immediately shortens when 
the extension is discontinued — especially if, at the same moment, the elbow is 
bent. This is a very important means of diagnosis. 

4. A careful measurement, made from the point of the internal condyle to the 
acromion process, declares a positive shortening of the humerus. 

5. By flexing and extending the forearm upon the arm, while the fingers are 
placed upon the lower portion of the humerus, the projecting fragments can be 
felt. Generally, the upper fragment being in front of the lower, and pressing 
down into the bend of the elbow, its end cannot be so easily recognized ; but 
the upper end of the lower fragment can easily be made out, posteriorly, when 
the forearm is considerably flexed. The lower end of the upper fragment feels 
more rough, and is less wide, than in dislocations. 

6. The whole of the lower fragment is carried backward, and with it the radius 
and ulna, producing a striking prominence of the elbow and olecranon process. 
Efforts to straighten the forearm upon the arm, when no extension is used, 
increase rather than diminish this projection. 

7. The forearm is slightly flexed upon the arm, the angle made at the elbow 
being 25 or 30 degrees. 

8. The hand and forearm are pronated. 

9. The relations of the olecranon process with the two condyles remain 
unchanged. 

In a case of epiphyseal separation, the lower end of the upper frag- 
ment has greater breadth than in the case of a fracture at the base of the 
condyle, and the line of separation is nearer the end of the bone. 

Signs of a Dislocation of the Radius and Ulna Backward.— I. Preternat- 
ural immobility — that is to say, extension and flexion are limited, but there is 
almost always present a preternatural lateral mobility. 

2. Absence of crepitus. It is in this joint especially that surgeons have been 
deceived by the charing of the dislocated bones upon the inflamed joint surfaces, 
and have supposed that they discovered crepitus when no fracture existed. The 
rapidity with which inflammation develops itself after dislocations of the elbow- 
joint, and the consequent abundant effusion of lymph, afford the probable expla- 
nation of this frequent error. 

3. When reduced, the bones are not generally disposed to become again dis- 
placed, even though the elbow should be flexed. 

4. The humerus is not shortened, but the olecranon process approaches the 
acromion process. 

5. There are no sharp projecting points of bone. The lower end of the 
humerus may not always be felt in the bend of the elbow ; but when it is felt, 
it is found to be relatively smooth, broad, and round. 

6. A remarkable prominence of the elbow and olecranon process, which promi- 
nence is sensibly diminished when an effort is made to straighten the forearm on 
the arm. 



240 FRACTURES OF THE HUMERUS. 

7. Forearm flexed upon the arm to about the same degree as in fracture. 

8. Hand and forearm pronated as in fracture. 

9. Eelations of the olecranon process to the condyles changed very greatly. 

The most constant diagnostic signs are, then, in the case of a fracture, 
crepitus, shortening of the humerus, projection of the sharp ends of the 
fragments, and an increase of the projection of the elbow when an 
attempt is made to straighten the arm; and in the case of a dislocation, 
the absence of crepitus, humerus not shortened, while the olecranon ap- 
proaches the acromion process ; the smooth, round head of the humerus 
lost, or indistinctly felt in the bend of the elbow, and the projection of 
the point of the elbow diminished when the attempt is made to straighten 
the forearm on the arm. 

It is proper, also, to repeat here what we have already said in relation to the 
causes of this fracture. A fracture of this point is produced almost always by 
a fall upon the elbow, but a dislocation of the radius and ulna backward can 
never be. On the other hand, a dislocation is produced, in most cases, by a 
fall upon the palm of the hand, while I have never known but one fracture 
above the condyles to be thus produced. 

Prognosis. — Nine times I have found the arm shortened from half an 
inch to one inch, or a little more. Moderate ankylosis is almost always 
present when the apparatus is first removed, and it is seldom completely 
dissipated until after several months ; but I have found more or less anky- 
losis at seven and nine months ; and twice after the lapse of three years 
the motions of the joint have been very limited. 

A few years since, I examined the arm of a gentleman who was then twenty- 
seven years old, and who informed me that when he was four years old he broke 
the humerus just above the condyles. There still remained a sensible deformity 
at the point of fracture— he could not completely supine the forearm. The 
whole arm was weak, and the ulnar nerve remarkably sensitive. The ulnar side 
of the forearm, and also the ring and little fingers, were numb, and have been 
in this condition ever since the accident. I know the surgeon very well who 
had charge of this case, and I have no doubt that the treatment was correct. 
In June of 1850 I operated upon a lad, nine years old, by sawing off the pro- 
jecting end of the upper fragment, whose arm had been broken nine months 
before. This fragment was lying in front of the lower, and the skin covering 
its sharp point was very thin and tender. There was no ankylosis at the elbow- 
joint, but the hand was flexed forcibly upon the wrist, the first phalanges of all 
the ringers extended, and the second and third flexed. Supination and prona- 
tion of the forearm were lost. The forearm and hand were almost completely 
paralyzed, but very painful at times. The ulnar nerve could be felt lying across 
the end of the bone. In the hope that a favorable change might result by reliev- 
ing the pressure on the nerve, yet with not much expectation of success, I exposed 
the bone and removed the projecting fragment. The nerve had to be lifted and 
laid aside. About one year from this time I found the arm in the same condition. 
Non-union is a result not so frequent in fractures at this point as higher up ; 
but Stephen Smith, of the Bellevue Hospital, New York, reports a case of non- 
union in a man of twenty-three years. He was admitted to the hospital on 
the seventh day after the accident. The fracture was simple and transverse, 
yet at the end of four months he was dismissed " with perfectly free motion 
at the point of fracture." 1 The failure to unite was attributed to a syphilitic 
taint. 

A case was tried a few years since in the Supreme Court at Brooklyn, N. Y., 

1 Stephen Smith, New York Journal of Medicine, May, 1857, third series, vol. ii. p. 386. 



BASE OF THE CONDYLES. 241 

in which, after a simple fracture at this point, the arm being dressed with splints 
and bandages, the little finger sloughed off in a condition of dry gangrene, and 
the adjacent parts of the hand were attacked with moist gangrene. Drs. Parker 
and Prince believed that this serious accident was the result of bandages applied 
too tightly and suffered to remain too long, while Drs. Valentine Mott, Rogers, 
Wood, Ayres, Dixon, and others, believed the gangrene might have been due to 
other causes over which the surgeon had no control. 1 

A few years ago, a similar case occurred in the town of Spencer, Tioga Co., 
N. Y. ; a boy, six years old, having broken the humerus just above the condyles. 
The fracture was oblique. The surgeon who was called to treat the case was an 
old and highly respectable practitioner. I am not informed of the plan of treat- 
ment any further than that a roller was applied. On the eighth day, a second 
surgeon was employed, who, finding the hand cold and insensible, removed all 
of the dressings; after which the thumb and forefinger sloughed, with other 
portions of the skin and flesh of the hand and arm. The surgeon who was first 
in attendance was prosecuted, and the case was tried in the Supreme Court of 
that county, but the jury found no cause of action. Dr. Hawley, of Ithaca, and 
the late Dr. Webster, of Geneva Medical College, testified that, in their opinion, 
the death of the fingers was owing to the pressure of the fragment upon the 
brachial artery, and not to the tightness of the bandages. 

Dr. Gross has also informed us of still another case of the same character, 
which occurred in Warren Co., Ky. A boy, ten years old, had broken his arm 
above the condyles, and his parents having employed a surgeon residing at 
some distance, the dressings were applied, and directions given to send for the 
surgeon whenever it became necessary. The parents saw the arm swell exces- 
sively, and knew that the boy was suffering very much, but did not notify the 
surgeon until the tenth day, when the hand was found to be in a condition of 
mortification, and at length amputation became necessary. Long afterward, in 
the year 1851, when the boy became of age, he prosecuted his surgeon, but with 
no result to either party beyond the payment of their respective costs. 

A similar case has been reported to me by Dr. Lyman Twomley, of Catta- 
raugus County, in this State. Dr. Twomley is a well-known and experienced 
surgeon and physician. Dr. T. was called to a boy set. 7, who had fallen ten 
feet and broken his right arm at the base of the condyles. Although but twelve 
hours had elapsed, the limb was greatly swollen. The lower end of the upper 
fragment projected through the skin three inches. His pulse was feeble and 
intermittent. Dr. T. administered chloroform and adjusted the fragments. 
Light splints were applied, and cold lotions. On the fifth day gangrene com- 
menced, and on the seventh day Dr. T. amputated at the point of fracture. 
The wound resulted in the formation of a good stump. Examining the limb 
after amputation, the joint was found filled with blood in a putrid state, and 
the tissues above and below were infiltrated with the same. Both of the lateral 
and the anterior ligaments of the joint were badly torn. The biceps and 
brachialis anticus were much torn. A small portion of the olecranon process 
and more of the coronoid processes were broken off. The brachial artery was 
ruptured, and the median nerve seriously injured. There was also a partial 
fracture of the carpal extremity of the radius. When this boy became of age 
he entered a suit against the doctor for malpractice, in having, he affirmed, 
made an unnecessary amputation of the arm. I am informed that the allega- 
tions were not sustained by the Court, and in this decision all surgeons must 
heartily concur. 

While I would not deny that in some of the preceding cases the sloughing 
might have been solely due to the tightness of the bandages, against which cruel 
and mischievous practice we cannot too strongly protest, a knowledge of the 
anatomy of these parts, and the opinions of the very distinguished gentlemen 
who testified in detence of these surgeons, must compel us to admit the possi- 
bility of such accidents where the treatment has been skilful and faultless. 

Treatment. — The splints formerly much employed in this country, in 
fractures about the elbow-joint, and perhaps still used by some American 

1 New York Medical Gazette, vol. xii. pp. 46, 80, 111. 
16 



242 



FRACTURES OF THE HUMERUS. 



surgeons, are simple angular side-splints, without joints, such as those 
recommended by Physick; 1 angular pasteboard splints, felt, leather, 
gutta percha, etc., or angular splints with a hinge, such as Kirkbride's, 2 
Thomas Hewson's, Day's, Rose's, Welch's, or Bond's. 

Kirkbride's splint, which is said to have been used in the Pennsylvania Hos- 
pital in several instances, is composed of two pieces of board, connected together 
by a circular joint, and having eyes in the inner edge, two inches apart, and 
holes through the splint at graduated distances between them. There is also a 
swivel eye, passing through the upper part of the splint, and riveted below. A 
wire is fastened to the swivel, and bent at right angles at its other extremity, of 
a size to tit the eyes and holes in the splint. The splint, properly supported by 
pads, is to be placed either upon the outside or inside of the arm, and secured 
by rollers. When the angle is to be changed, the wire is unhooked and removed 
to another eye, or to some of the intermediate holes upon the side of the splint. 



Fig. 120. 



Fig. 121. 




Welch's -splint. The hinges may be transferred 
to splints of different sizes. 

Dr. Kirkbride reports two cases of fracture of the lower part of the humerus 
treated by this plan, one of which resulted in ankylosis, but the other was much 
more successful. 

H. Bond, of Philadelphia, has contrived a very ingenious splint for the elbow- 
joint, and which is designed also to afford a complete support to the forearm. 

For myself, I generally prefer a thick sheet of gutta percha, moulded 
and applied accurately to the limb. It should be extended beyond the 
elbow to the wrist, so as to support the whole length of the arm, elbow, 
and forearm. Some experience in the use of wooden angular splints has 
convinced me that they cannot be very well fitted to the many inequali- 
ties of the limb ; and neither pasteboard nor binder's board has sufficient 
firmness, especially in that portion which covers the joint. Angular 
splints, furnished with a movable joint, possess the advantage of enabling 

1 Elements of Surgery, by John Syng Dorsey, Philadelphia edition, vol. i. p. 145. 

2 American Journal of the Medical Sciences, vol. xvi. p. 315. 



BASE OF THE CONDYLES. 

Fig. 122. 



243 




Bond's elbow splint. 

us to"change the angle of the limb at pleasure, and of keeping up some 
degree of motion in the articulation without disturbing the fracture or 



nng the dressings : but the 



Fig. 123. 



crossbars of Day's and Rose's 
splints render them complicated, 
and are in the way of a nice ap- 
plication of the rollers ; while they 
are all equally liable to the objec- 
tion stated against angular wooden 
splints without joints, viz., that 
they seldom can be made to fit 
accurately the many irregularities 
of the arm, elbow, and forearm. 
In applying the author's splint, 
care must be taken that the hu- 
meral portion is not too short, or 
the result will be an unnecessary 
degree of overlapping of the frag- 
ments. This may generally be 
avoided if the surgeon will first 
shape his material to the sound 
arm, while the whole length is 
underlaid with three or four thick- 
nesses of woollen cloth. Welch's 
splints, made of a material pos- 
sessing a slight amount of flexi- 
bility, approach more nearly the accomplishment of all the indications 
than any other manufactured splint with which I am acquainted, but the 
number of cases in practice to which they are applicable will be found to 
be limited, while gutta percha has no limit in its application. 

Whatever material is employed, the splint should be first lined with one 
thickness of woollen cloth, or some proper substitute. A pretty large pledget of 
fine cotton batting ought also to be laid in front of the elbow-joint, to prevent 
the roller from excoriating the delicate and inflamed skin ; and great care should 




The author's gutta-percha splint. 



244 FRACTURES OF THE HUMERUS. 

be taken to protect the bony eminences about the joint, or, rather, to relieve 
them from pressure, by increasing the thickness of the pads above and below 
these eminences. 

At a very early day, so early, indeed, as the seventh or eighth day, 
the splint should be removed, and, while the fragments are steadied, the 
joint should be subjected to gentle, passive motion. This practice should 
be repeated as often as every second or third day, in order to prevent, 
as far as possible, ankylosis. If much swelling follows the injury, it is 
my custom to open the dressings, without removing the splints, on the 
second or third day after the accident, or at any time when the symp- 
toms admonish of its necessity. Occasionally, it is well to change the 
angle of the splint before reapplying it. If the angular splint with a 
movable joint is used, slight changes may be made while the splint is on 
the arm ; but if the angle is much changed without removing the roller, 
they become unequally tightened over the arm and may do mischief. 

[The plaster-of- Paris dressing should be preferred by those accustomed to its 
use. The fracture should be reduced and the fragments held in position until the 
dressing is firm. It should extend from the wrist to the shoulder. The neces- 
sity for passive motion during the first three weeks is not so great as to preclude 
immovable dressings. Indeed, it is believed by many surgeons that early passive 
motion in this fracture is decidedly detrimental and should never be practised.] 

When ankylosis has actually taken place, we may more or less over- 
come the contraction of the muscles and of the ligaments by gentle passive 
motion, or by directing the patient to swing a dumb-bell or some other 
heavy weight, as first recommended by Hildanus ; but we must bear in 
mind the danger of causing a refracture by too early or immoderate force. 

§ 7. Fracture at the Base of the Condyles, complicated with Fracture 
between the Condyles, extending into the joint. 

This fracture, which is but a variety or complication of the preceding, 
is even more difficult of diagnosis ; and its signs, results, and proper 
treatment differ sufficiently to demand a separate 
Fig. 124. consideration. I have recognized the accident 

six times. Confined to no period of life, it seems 
to be the result of a severe blow inflicted directly 
upon the lower and back part of the humerus, or 
upon the olecranon process. 

Dr. Parker, of New York, was inclined to regard an 
obscure accident about the elbow-joint, which he saw 
in a lad sixteen years old, as a longitudinal fracture 
of the humerus, with separation of one condyle, but 
which had been occasioned by a fall upon the hand. 1 
For myself, I should regard this latter circumstance 
as presumptive evidence that it was not a fracture of 
this character, yet I do not mean to deny the possi- 
Fracture at the base of, and bility of its occurrence in this way. 
between, the condyles. 

Symptoms. — The symptoms are, increased 
breadth of the lower end of the humerus, occasioned by a separation of 
the condyles ; displacement upward and backward of the radius and 

1 Parker, New York Journal of Medicine, Nov. 1856, p. 391, 3d series, vol. i. 




FRACTURE AT THE BASE OF THE CONDYLES. '245 

ulna ; shortening of the humerus ; crepitus and mobility at the base of 
the condyles, with crepitus also between the condyles, developed by 
pressing them together ; or in case the radius and ulna are drawn up 
and back, the crepitus may be detected, after restoring these bones to 
place, by pressing upon the opposite condyles. Its consequences are, 
generally, great inflammation about the joint, permanent deformity,. and 
bony ankylosis. An opposite result must be regarded as fortunate, and 
as an exception to the rule. 

The treatment must be chiefly directed to the prevention and reduc- 
tion of inflammation ; at least during the first few days. Nor is this 
inconsistent with an early reduction of the fragments, and moderate 
efforts, by splints and bandages, such as I have directed in case of a 
simple fracture at the base of the condyles, to keep the fragments in 
place. No surgeon would be justified in refusing altogether to make 
suitable attempts to accomplish these important indications ; but he must 
always regard them as secondary when compared with the importance of 
controlling the inflammation. When splints are employed, the same 
rules will be applicable, both as to their form and mode of application, 
as in cases of simple fracture above the condyles. Plaster-of- Paris, or 
some of the immovable forms of dressing, furnished with ample fenestra, 
will sometimes be preferred. 

The following will more completely illustrate the character, history, and 
proper treatment of these cases than any remarks or rules which I can present: 
A woman, set. forty-four, fell upon the sidewalk, striking upon her right elbow. 
I saw her a few minutes after the accident, but the parts about the joint, were 
already considerably swollen, and it was not without difficulty that the diagnosis 
was made out. The forearm was slightly flexed upon the arm, and pronated. 
On seizing the elbow firmly, a distinct motion was perceived above the condyles, 
and a crepitus. I could also feel, indistinctly, the point of the upper fragment. 
While moderate extension was made upon the arm, the condyles were pressed 
together, when it was apparent that they had been separated. On removing the 
extension, they again separated, and the olecranon drew up. She was in a con- 
dition of extreme exhaustion, and the bones were easily placed in position. An 
angular splint was secured to the limb, and every care used to support the frag- 
ments completely, but gently. From this date until the conclusion of the treat- 
ment the dressings were removed often, and the elbow moved as much as it was 
possible to move it. Seven months after the accident, the elbow was almost 
completely ankylosed at a right angle. The fingers and wrist, also, were quite 
rigid. Six years later, the ankylosis had nearly disappeared ; she could now 
flex and extend the arm almost as much as the other; the wrist-joint was free, 
and the fingers could be flexed, but not sufficiently to touch the palm of the 
hand. The line of fracture through, the base could be traced easily, but the 
humerus was not shortened. There was, moreover, much tenderness over the 
point of fracture through the base, and at other points. Occasionally, a slight 
grating was noticed in the radio-humeral articulation. She experienced fre- 
quent pains in the arm, and especially along the back and radial border of the 
ring finger. During the first year or two after the accident, the arm wasted 
very much ; the hand remained weak, but the muscles were well developed. 
A gentleman was struck with the tongue of a carriage with which a couple of 
horses were running. The blow was received directly upon the back of the left 
elbow. Dr. Sprague and myself removed some small fragments of bone, and 
while opening the wound for this purpose, we could see distinctly the line of 
fracture extending into the joint as well as across the bone. The condyles were 
not separated. The subsequent treatment consisted only in the use of such 
means as would best support the limb, and most successfully combat inflamma- 
tion. The arm and forearm were laid upon a broad and well-cushioned angular 



246 FRACTURES OF THE HUMERUS. 

splint, covered with oil-cloth, to which they were fastened by a few light turns 
of a roller. Twelve years after, I found the humerus shortened one inch and a 
half. During the first year, he says, there was no motion in the elbow-joint, 
but he can now flex and extend the forearm through about 45° ; when flexed to 
a right angle, it seems to strike a solid body like bone. Eotation of the forearm 
is completely lost, the hand being in a position midway between supination and 
pronation. He suffers no pain, and his arm is quite strong and useful. No 
means have been employed to restore the functions of the limb but passive mo- 
tion at first, and subsequently constant, active use of the hand and arm. 

Although the flexed position must usually be regarded as the best in 
these fractures, for the reason that it most completely relaxes the biceps, 
brachialis anticus, and the flexors of the forearm, and because if anky- 
losis ensues the flexed position gives the most useful arm, yet I think it 
might be proper to try what better may be accomplished by permanent 
extension, with the forearm straightened upon the arm, according to the 
method of Dr. Clark, described in the preceding pages. 

In a case of compound comminuted fracture of the character now under con- 
sideration, Dr. Stone, of the Bellevue Hospital, New York, removed the condyles 
and sawed off the sharp end of the humerus. The woman was twenty-six years 
old and intemperate. The operation was made as a substitute for amputation. 
No serious complications followed. On the ninety-sixth day the wounds were 
completely healed, and she could bend the forearm to a right angle with the 
arm, the action of the muscles having drawn up the radius and ulna against the 
lower end of the shaft of the humerus, so that the motions were natural and free. 1 
The practice, as the result sufficiently shows, was eminently judicious; and its 
practicability ought always to be well considered before resorting to the serious 
mutilation of amputation. The great principle upon which the success of resec- 
tion is here based is the shortening of the bone, whereby the reduction may be 
accomplished without painful tension to the muscles; a principle which will 
demand of us hereafter a more careful consideration and a wider application. 

[The resection of the joint in compound comminuted fractures of the lower 
end of the humerus is now a safe operation. It is important that the condition 
of the parts be thoroughly understood, and that the operation leave the joint in 

Fig. 125. 




Plaster-of- Paris dressing with iron bands. 

the best possible state for future use. Fibrous tissues should be saved, and, if 
possible, the muscular attachments to the coronoid and coracoid processes. A 
useful splint, after such an operation, is made with iron bands, properly bent, 
and the plaster-of-Paris dressing.] 

1 Stone, New York Journ. of Med., May, 1851, p. 302, vol. vi. 2d series. 



FKACTURES OF THE INTERNAL EPICONDYLE. 247 



Fractures and. Diastases of the Condyles and, Epicondyles. 

I prefer, as being more familiar, the terms external and internal con- 
dyles, to which it will be convenient to add the terms external epicondyle 
and internal epicondyle, as indicating the abrupt lateral projections on 
either side of the condyles, of which the largest portions are epiphyseal. 
These crests or projections are formed in part by a prolongation of the 
outer and inner elevated margins of the humerus, and in part from sep- 
arate centres of ossification, which in early life mainly overlie the two 
sides of the lower epiphysis. In advancing years these lateral epiphyses 
prolong themselves upward to reach and partially overlie the humeral 
portions : the outer epiphysis becomes united by bony tissue to the shaft 
or humeral apophysis, about the sixteenth or seventeenth year ; while 
the inner epiphysis, much larger than the outer, is not united usually to 
its corresponding apophysis until the eighteenth year. Gurlt places the 
period of union of both of these epiphyses a year or two later. 

I shall hereafter speak of the epicondyles as all of those portions of 
the lower end of the humerus which project abruptly from the condyles, 
and are composed in large part of the lateral epiphyses, but not entirely. 
Practically, this definition leaves no portion of the lower extremity of the 
humerus outside of the capsule except the epicondyles. We shall there- 
fore have to speak only of fractures of the epicondyles, and of fractures 
of the condyles involving the joint ; the condyles proper, as distinguished 
from the epicondyles, constituting on the one hand the outer end of the 
lower extremity of the humerus, including so much of the articular sur- 
face as belongs to the eminentia capitata ; and, on the other hand, so 
much of the inner portion of the aiticular surface as includes the trochlea. 
The epi condylar separations consist of two varieties, one of which is an 
epiphyseal separation, and the other a true fracture ; one of which in- 
cludes only a portion of the epicondyle, and the other includes the whole. 
The remaining fractures will all be intracapsular. 

§ 8. Fracture of the Internal Epicondyle ; and Fracture or Diastasis 
of the Internal Epicondylar Epiphysis. 



I will here add, to what I have already said in the preceding pages on 
the anatomy and development of the humerus, the very careful descrip- 
tion of the development of the lower end of the humerus given by Dr. 
Zuckerkandl, Demonstrator of Anatomy in the University of Vienna. 1 



"The inferior extremity of the humerus proceeds from a synostosis of five 
separately developed portions of bone. These are: 1st, the humeral-diaphysis, 
which includes the supra-trochlear fossa, a minute portion of the eminentia 
capitata, and on the dorsal surface the ribbon-like zone of the trochlea; 2d, the 
trochlea ; 3d, the eminentia capitata ; 4th and 5th, the epicondyles. On the 
fully -formed humerus that part is called the internal epicondyle which projects 
lever-like above the trochlea, and serves as the point of origin of the flexor 
group. Though this bony prominence presents itself as a united whole at this 
stage, still an examination of the humerus, in the earlier periods of its develop- 
ment, teaches us that the internal epicondyle of the adult consists of two pieces, 

1 Zuckerkaucll, on the Epicondylar Fracture of the Humerus. Hosp. Gazette, Sept. 27, 
1879. Separat-Abdruck aus der "Algem. Wiener Mediz. Zeitung/' 187b, jSTr. 9. 



248 FRACTURES OF THE HUMERUS. 

the superior of which belongs to the humeral diaphysis, to the median surface 
of which the osseous nucleus of the epicondyle applies itself, enlarges, and 
finally unites with the upper portion to form the lever of the flexor group of 
. muscles. Accordingly what, in ordinary acceptation, is called a fracture of the 
epicondyle is something more, since it includes also a part of the humerus. It 
is difficult to believe that only that part of the internal epicondyle which cor- 
responds to the epiphyseal centre of ossification, should be broken off in the 
adult, so that distinct cases of epicondylar fracture can occur only in youths. 
" What we call external epicondyle, on the completely developed humerus, 
and a small portion of which (called 'la petite saillie,' in the above quotation 
from Malgaigne) can be felt and seen through the skin of the arm in lean sub- 
jects, belongs, as taught by em'bryological observations, not properly to the 
external epicondyle, but represents the most inferior prominence of the crista 
externa humeri, with which the more posteriorly extending epiphyseal nucleus 
of the external epicondyle finally unites. The epicondyles of adults, therefore, 
belong partly to the humerus and partly to the actual epiphyseal epicondyles, 
as a glance at the humeri of young persons teaches us. From the real internal 
epicondyle, which we term epiphyseal, arise the radialis internus, ulnaris inter- 
nus, palmaris longus, and a small portion of the pronator teres, while from that 
part of the epicondyle which belongs to the humeral diaphysis, arises the greater 
portion of the pronator above named. On the external epiphyseal epicondyle 
are found the common extensor of the fingers, the ulnaris externus, and the 
anconeus quartus." 

These views of the anatomy and development of the condyles and 
epicondyles, and which are no doubt correct, compel me to reconsider 
the statements I have made in the earlier editions of this w T ork, and to 
correct certain errors into which the author, in common with all other 
writers, has fallen in the classification of certain reported examples of 
fractures of the epicondyles. Hitherto, while in speaking of fractures 
of the internal epicondyle, I have distinctly stated that my remarks were 
limited to separations of the epicondylar epiphyses, I have not hesitated 
to include as proper examples those cases in which I believed the entire 
epicondylar projection to be included. Other writers have, without 
exception so far as I know, done the same. The observations of Zuck- 
erkandl, however, show that, as I have before stated, these extreme pro- 
jections are composed only in part of the true epicondylar epiphyses. 
We must then hereafter speak of these separations which are epicon- 
dylar, and only epiphyseal, as composing one class of accidents, and 
which must be in a great measure peculiar to children ; and of those 
which are epicondylar, but include also that portion of the epicondyle 
which is not epiphyseal, as another class, belonging chiefly to adults, but 
possible in children. 

According to Zuckerkandl, it has been observed by Rambaud and 
Renault that there is sometimes a persistence of the epiphysis, the sepa- 
ration continuing to adult life ; from which we must infer that an epi- 
condylar epiphyseal diastasis might take place in the adult, but it must 
nevertheless be very infrequent. We can have, usually, no means of 
determining this point except in the autopsy, and we must therefore be left 
in doubt sometimes whether a particular clinical case is to be regarded 
as an epiphyseal separation or a true fracture ; our only means of differ- 
ential diagnosis being the probabilities afforded by the age of the patient, 
the cause, and the size and form of the fragment. 

In treating of this subject, then, we can only relieve ourselves of the 
embarrassment by treating of epicondylar fractures and diastases as a 



FRACTURES OF THE INTERNAL EPICONDYLE. 249 

class, existing in two subordinate forms — namely, one in which only the 
epiphysis is torn off before bony union to the crista humeri has taken 
place — a true diastasis ; and the second, in which, bony union having 
been completed, the whole of the extreme projection or epicondyle is 
separated from the shaft — a true fracture. The differential diagnosis of 
these two forms of injury to the epicondyle is somewhat difficult to estab- 
lish by external signs. The age of the patient is doubtless the most im- 
portant consideration, and in this view diastasis must be regarded as by 
far the more frequent accident. 

This is probably the accident which Granger first described, and which 
he ascribed solely to muscular action. He does not speak of it, however, 
as a diastasis of the epicondyle, but as "a particular fracture of the 
internal condyle." "A circumstance attending this fracture," says Mr. 
Granger, "is that of its being occasioned by sudden and violent muscu- 
lar exertion ; and it will be recollected that from the inner condyle those 
powerful muscles which constitute the bulk of the fleshy substance of the 
ulnar aspect of the forearm have their principal origin. The way in 
which the muscles of the inner condyle are involuntarily thrown into 
such sudden and excessive action I take to be this : the endeavor to pre- 
vent a fall by stretching out the arm, and thus receiving the percussion 
from the weight of the body on the hand." 1 

It is a fact of significance in this connection, that most of these frac- 
tures hitherto reported as epicondylar have occurred in children, before 
the union of the epiphysis is completed, when muscular contraction might 
more often prove adequate to its separation, and when the epicondyle is 
less prominent, and, therefore, less exposed to direct blows, than in adult 
life. 

M. A. Cesar has collected fourteen cases, of which number only four were 
adults, two were from eight to ten years old, five from eleven to twelve, and 
three from fifteen to sixteen. 2 While of five fractures which I have regarded 
as fractures of the epicondyle, all except one occurred between the ages of two 
and fifteen years. 

It is equally true that a large majority of all the fractures of the 
internal condyle, including those which enter the articulation, as well as 
those which do not, belong to childhood and youth. I have seen but two 
exceptions in fifteen cases. Since, then, direct blows generally produce 
those fractures which penetrate the joint, no good reason can be shown 
why they should not sometimes produce fractures of the epicondyle. 
One of the exceptions to which I have referred as not having occurred 
in early life, is sufficiently rare to entitle it to especial notice. 

A laborer, thirty-four years of age fell from an awning upon the sidewalk, 
dislocating the radius and ulna backward; the dislocation was immediately 
reduced by a woman who came to his assistance, but when he called on me soon 
after, I found a small fragment of the inner condyle, probably the epicondyle 
alone, broken off and quite movable under the finger. It was slightly displaced 
in the direction of the hand. I could not learn positively whether in falling he 
struck the elbow or the hand, but there was presumptive evidence that he struck 

1 " On a Particular Fracture of the Inner Condyle of the Humerus," by Benjamin 
Granger, Surgeon, Burton-upon-Trent. Edinburgh Med. and Surg. Journ., vol. xiv. p. 
196, April, 1818. 

2 Cesar, Essai sur le frac. de l'epitrochlee, th. de Paris, 1876. 



250 FRACTURES OF THE HUMERUS. 

the hand ; if so, then probably the fracture was the result of muscular action, 
which is the more extraordinary as having taken place in a man of his age, but 
in which case it must be assumed that the epiphyseal union was delayed. 

It is pretty certain, however, that the theory of causation adopted by Granger 
is too exclusive. A lad was brought to me, aged eleven, who had just fallen 
upon his elbow, the blow having been received, as he affirmed, and as the ecchy- 
mosis showed pretty conclusively, directly upon the inner condyle. The frag- 
ment was quite loose, and crepitus was distinct. He could flex and extend the 
arm, and rotate the forearm, without pain or inconvenience. I am quite sure 
the fracture did not extend into the joint ; the result seemed also to confirm this 
opinion, for in three months from the time of the accident the motions of the 
elbow-joint were almost completely restored. Out of fourteen cases collected by 
Cesar, at least eight, says Poinsot, were produced by a direct cause. 

Mr. Granger has failed to establish, by any particular proofs, that in 
more than one or two of his cases the fracture was the result of muscular 
action ; but, on the contrary, I am disposed to infer, from the violent 
inflammation which generally ensued in his cases, from the frequency of 
ecchymosis, and especially from the injury done to the ulnar nerve in at 
least three instances, that most of them were produced by direct blows 
inflicted from below in the fall upon the ground. Fractures produced by 
muscular action are seldom accompanied with much inflammation or effu- 
sion of blood, and it is much more probable that the ulnar nerve should 
have been maimed by the direct blow which caused the fracture, than by 
the displacement of the epiphysis, which is, as I shall presently show, 
almost always carried downward, and oftener slightly forward than back- 
ward. It is only when the fragment is forced directly backward that the 
ulnar nerve could be made to suffer ; a direction which, it does not seem 
me, it could ever take from muscular action alone. 

Of all the cases above alluded to, including Granger's cases, it may be justly 
said that they were not verified by an autopsy, and that they do not, therefore, 
prove absolutely the existence of such a diastasis. In a case reported by Denuce, 
there was an exostosis resulting from a fracture, which caused paralysis of the 
ulnar nerve ; but there is no evidence that the injury to the nerve was the result 
of displacement of the fragment. It was cured, however, by excision of the 
exostosis, 1 

Poinsot suggests that when a fracture of the internal epicondyle is 
caused by a fall upon the hand, the result may sometimes be due rather 
to the action of the internal lateral ligament than to muscular action ; 
and he says that Granger, Fergusson, Dale, and Richet have observed 
cases of this kind. He, however, refers to one case mentioned by Hirtz, 
in which the accident was declared to be plainly the result of muscular 
action, it being occasioned in a little boy by the act of raising himself by 
his arms while suspended from a trapeze. 

Malgaigne speaks of this accident as a "fracture of the epitrochlea," 
evidently including in this term all of the epicondylar projection. He 
states, however, that " there is good ground for supposing that in some 
cases, at least, it is a disjunction of the epiphysis." Gurlt distinctly 
states, also, that clinical experience shows that both the inner and outer 
epiphyses are sometimes broken, however difficult it may be to demon- 
strate the fact anatomically. The case of which he furnishes an illus- 

1 Poinsot, op. cit., pp. 314-317. 



FRACTURES OF THE INTERNAL EPICONDYLE. 



251 



tration in his book (p. 797, Fig. 109), and as being in the pathological 
collection at Wiirzburg, may indeed have been a fracture of the entire 
internal epicondyle, including both the epiphysis and the apophysis, but 
there is no evidence or pretence that it was the epiphysis alone. 1 

The specimen described by Zuckerkandl, found in the dissecting-room, and 
without a clinical history (Fig. 126), and which he has kindly sent to me, is 
probably the only example of which we can speak with any degree of positive- 
ness as having been sustained by an autopsy. The following is his account: 
''The separation of the internal epicondyle I found on the left arm of a strong- 
boned man. After the removal of the flexors, the epicondyle appeared projecting 
forward tumor-like, but immovable, so that at first sight I thought of a fracture 
healed by callus. As I removed the dense connective tissue, which surrounded 
the epicondyle, there appeared a furrow, which encircled the irregular bony 
prominence, and formed a sharp line of demarcation between it and the humeral 
epicondyle. The tumor-like bony prominence, therefore, represented the epiph- 
yseal epicondyle. On farther examination it was seen that the epiphyseal was 
connected with the humeral epicondyle only by a dense tissue, was irregularly 
formed on its uneven upper surface, slightly concave on its superior attached 
side, and of about the size of an os lunatum. In the figure are plainly seen the 
intact humeral epicondyle, the epiphyseal epicondyle, and between them the 
above-described furrow, which was filled with fibrous tissue. The separated 
epicondyle does not correspond in form to that of a youthful person, nor to the 
inferior part of the flexor condyle in the adult. Its long axis in the latter is 
parallel with that of the humerus — in our preparation, however, it is sagittal 
twisted, as it were, on its axis. The inferior portion of the epicondyle is in the' 
adult about one-half cm. distant from the edge of the trochlea, but it is more 
than one cm. removed in this preparation; so that the lateral surface of the 
trochlea is very deep." 

The bone is from an adult, as stated by Dr. Zuckerkandl, but he has omitted 
to mention that the coronoid fossa is small, and the olecranon fossa is nearly 
obliterated, indicating that for a 

long time before death the motions of Fig. 126. 

the joint were limited. The pre- 
sumption is, therefore, that this was 
an old fracture ; a fact which in- 
creases greatly the difficulty of deter- 
mining precisely the original char- 
acter of the accident. There is a 
broad vertical and remarkable facet 
mentioned by Dr. Zuckerkandl on 
the inner side of the trochlea ; the 
outer condyle is probably not normal 
in its shape, and altogether there are 
indications that the bone has at some 
time suffered a very severe and per- 
haps complicated injury. Perhaps 
there was more than one line of frac- 
ture ; possibly a transverse fracture 
through the shaft at the base of the 
condyles, or through the line of the 
epiphyseal junction. If such were 
the fact, the specimen does not illus- 
trate a simple fracture of the epi- 
condyle ; but these are points which 
the ancient character of the fracture 
does not permit us to determine positively. We think, however, this may 
properly be called a separation of the epiphyseal portion of the internal epi- 




Separation of the epiphyseal portion of the in- 
ternal epicondyle. (Zuekerkandl's specimen.) 



1 Handbuch der lehre von den Knochenhrlichen. Von Dr. E. Gurlt, Prof, der Chirurgie 
an der Kb'niglichen Universitat zu Berlin. Hamm, 1862, pp. 796, 797. 



252 FEACTURES OF THE HUMERUS. 

condyle, but whether it was a simple fracture or separation, uncomplicated with 
any other lesion of the bone, cannot now be determined. 

Direction of Displacement, Symptoms, etc. — I have seen what I sup- 
pose to be this epiphysis displaced in the direction of the hand, or down- 
ward, very manifestly, twice, and in two other examples a careful meas- 
urement showed a slight displacement in the same direction. 

The greatest displacement occurred in a boy fifteen years old. He had fallen 
upon his arm in wrestling, and his surgeon found a dislocation of the bones of 
the elbow-joint, which he immediately reduced. The diastasis of the epicondyle 
was not at that time detected, the arm being greatly swollen. No splints were 
applied. It was three months after the accident when I saw him, at which time 
I found the internal epicondyle removed downward toward the hand one inch 
and a quarter; and at this point it had become immovably fixed. Partial anky- 
losis existed at the elbow-joint, but pronation and supination were perfect. In 
one instance I believed the fragment to be carried about three lines upward and 
two backward toward the olecranon ; in each of the other examples the frag- 
ment did not seem to be displaced. 

Granger found, also, in the five examples which came under his notice, the 
epicondyle carried toward the hand, with more or less variation in its lateral 
position, so that while in some instances it touched the olecranon, in others it 
was removed an inch or more in the opposite direction. 

It is probable that, except where controlled by the force and direction 
of the blow, or by some complications in the accident, the fragment, if 
displaced at all, always moves downward toward the hand, or downward 
and a little forward, in the direction of the action of the principal 
muscles which arise from this epiphysis ; and when the fracture or sepa- 
ration is the result of muscular action alone, this form of displacement 
seems to me to be inevitable. In addition to the small size, mobility, 
crepitus, and generally slight displacement of the fragment, which, in 
connection with the age of the patient, are the principal signs of this 
fracture, it may be noticed that there is usually some embarrassment in 
the motions of the elbow-joint, which may be due in part to the swelling, 
and in part to the detachment of the point of bone from and around 
which most of the pronators and flexors of the forearm have their rise. 
In one instance, already quoted, that of the lad aged eleven years, who 
is supposed to have had a detachment of the epiphysis from a direct 
blow, the motions of pronation, with flexion, were not at all impaired, 
neither immediately, nor at any subsequent period, but the fragment was 
never sensibly, or only very slightly displaced. 

Granger has recorded another class of symptoms, to which I have already 
alluded, his explanation of which, however, I am not prepared to admit. One 
of these cases he describes as follows : A boy, eight years old, fell with violence, 
and broke off completely the whole of the inner epicondyle of the right 
humerus. The lad said he had fallen on his hand. The fragment was displaced 
toward the hand. Severe inflammation followed, but he recovered the free and 
entire use of the elbow-joint in less than three months after the accident. No 
splints or bandages were ever employed. From the moment of the accident, 
the little finger, the inner side of the ring finger, and the skin on the ulnar side 
of the hand, lost all sensation. The abductor minimi digiti and two contiguous 
muscles of the little finger were also paralyzed. This condition lasted eight or 
ten years, after which sensation and motion were gradually restored to these 
parts. As a consequence of this paralyzed condition of the ulnar nerve, also, 
successive crops of vesications, about the size of a split horse-bean, commenced 



FRACTUKES OF THE INTERNAL EPICONDYLE. 25S 

to form on the little finger and ulnar edge of the hand some weeks after the 
accident, leaving troublesome excoriations. This eruption did not entirely cease 
for two or three months. 

Mr. Granger says he found "the same paralysis of the small muscles of the 
little finger, the same loss of feeling in the integuments, and the same succes- 
sion of crops of vesicles on the affected parts of the hand, as occurred in the 
preceding case, in two other cases." 

Prognosis. — As in other accidents about the elbow-joint, a temporary 
rigidity is likely to ensue. The mere confinement of the arm in a flexed 
position is sufficient to determine this result without the interposition of 
a fracture ; but when inflammation occurs, more or less contraction of 
the tendons, muscles, etc., about the joint must ensue. To this circum- 
stance, therefore, added to the confinement, rather than to the fracture, 
w T ill be due the ankylosis. If the fragment is not displaced, the frac- 
ture cannot certainly be responsible for the loss of motion, since it does 
not in any way involve the joint ; and if displacement exists, its ulti- 
mate effect in diminishing the power of the muscles which arise from the- 
epiphysis must be only trivial and scarcely appreciable. We might, 
therefore, reasonably conclude that where the accident has been prop- 
erly treated, permanent ankylosis would be the exception, and not tho 
rule. 

This view of the matter seems also to be sustained by the recorded results.. 
In Granger's cases, the full range of flexion and extension of the forearm has 
been finally restored, or with so trifling an exception as not to be observable 
without close attention, in every instance ; except in the one already mentioned, 
which was originally complicated with dislocation; and even in this case the- 
ultirnate maiming was inconsiderable. Malgaigne, who says "it ought to be 
understood that in this accident articular rigidity is almost inevitable," seems 
nevertheless to admit the justness of Granger's observation as to the final result, 
if the proper means are employed to prevent it. I have myself found only once 
any considerable ankylosis of the joint after the lapse of a few years. 

[Powers, 1 of New York, reports ten cases, of which nine regained the func- 
tions perfectly, and the other had motions nearly complete when lost sight of.. 
In none was there deformity.] 

Treatment. — This accident does not constitute an exception to the rule- 
w r hich experience has established, that small epiphyseal projections, when 
once displaced, can seldom be restored completely to, or maintained in 
position. 

Granger remarks : "I have purposely avoided saying one word about replacing 
the detached condyle" (epicondyle), "and for these reasons: during the state 
of tumefaction of the limb, no means could be adopted for confining the re- 
tracted condyle in its place, beyond that of the relaxation of the muscles ; and 
both before the tumefaction has commenced, and after it has subsided, all 
endeavors to replace the condyle, or even to change the position of it, have 
failed." He even proceeds so far as to declare that, while attention ought to be 
given to the reduction of the inflammation by appropriate means, we ought, 
nevertheless, to instruct the patient to flex and extend the arm daily from the 
moment the accident occurs until the cure is completed, and without any regard 
to the consolidation of the fragment; "the exercise of the joint in this manner 
must constitute the principal occupation of the patient for several weeks; and 
should it be remitted during the formation and consolidation of the callus, much 

1 Med. Record, Dec. 22, 1888. 



254 FRACTURES OF THE HUMERUS. 

of the benefit which may have been derived from this practice will be lost, and 
will with difficulty be regained." With only slight qualifications I would adopt 
the advice of Mr. Granger. 

The limb ought, at first, to be placed in a position of semiflexion, so 
that if ankylosis should unfortunately ensue, it would be in the condi- 
tion which would render it most serviceable, and also because in this 
position the muscles which tend to displace the fragment would be most 
completely relaxed. While thus placed, an attempt ought to be made, 
by seizing the epiphysis, to restore it to position ; and if the effort suc- 
ceeds, as it certainly is not very likely to do, a compress and roller 
ought to be so applied as to maintain it in position; provided, always, 
that it shall not be found necessary to apply the roller so tight as to 
endanger the limb, or increase the inflammation. An angular splint 
would be an almost indispensable part of the apparel, at least with 
children, where this indication is in view. In no case, however, ought 
more than fourteen days to elapse before all bandaging and splinting 
should be abandoned, and careful but frequent flexion and extension be 
substituted. 

[The plaster-of-Paris dressing after about the sixth day gives excellent results. 
The forearm should be placed at an angle of ninety degrees with the arm, mid- 
way between pronation and supination ; the plaster bandage should be carefully 
applied from the wrist to the upper third of the arm, care being taken to cover 
the parts well with cotton wadding. The turns of the bandage should not press 
too firmly at the elbow. Examine the joint at the end of ten days, and renew 
the dressing. After the dressing is finally removed the motions are best re- 
stored by bathing with hot water and persistent use.] 

In three cases seen by me, a displacement of the fragment, either forward or 
backward, has occurred whenever the arm was flexed, and it has been necessary, 
therefore, to treat the case with the arm in a straight position. These are plainly 
only exceptions to the rule. 

§ 9. Fracture or Diastasis of the External Epicondyle. (Epicondyle, 

Chaussier.) 

The anatomy of the external epicondyle has already been described 
when speaking of the epicondyles generally. Like the internal epicon- 
dyle, it is composed in part of an epiphysis, and in part an apophysis 
projected from the shaft of the humerus, which portions become united 
to each other by bony tissue, usually about the sixteenth or seven- 
teenth year of life; occasionally the consolidation is delayed much 
longer. It is very small, and serves for the attachment of some of 
the common extensors of the forearm and hand, and the external lateral 
ligament. 

Whether this small epicondyle — speaking now of it as a whole, com- 
posed in part of the epiphysis and in part of the process from the shaft 
of the humerus — can be broken off or separated as a traumatic accident, 
and as a simple, uncomplicated fracture, needs no longer to be discussed. 
It is plainly impossible, unless the line of fracture includes a portion of 
the joint, and in that case it is to be designated as a fracture of the con- 



FRACTURES OF THE INTERNAL CONDYLE 



255 



dyle, and not of the epicondyle. At least I may say that no satisfactory 
clinical example or anatomical specimen has ever been presented. It is 
not difficult to admit, however, the possibility of 
a detachment of the epiphyseal portion prior to FiG - 127 - 

its consolidation with the shaft of the humerus ; 
and, indeed, the occurrence of such an accident 
would seem quite probable, yet we lack any abso- 
lutely conclusive evidence that it has ever taken 
place. 

The specimen of Zuckerkandl, of Vienna, will not 
bear the test of a critical examination. It was found 
in the dissecting-room, and is unaccompanied with any 
clinical history ; bnt it is evidently from a person near 
the twentieth year of life. There is, indeed, an ap- 
parent absence of a portion of the external epicondyle, 
and there are two ossicula, situated in the external 
lateral ligament, with smooth, slightly bosselated sur- 
faces. Dr. Z. explains the presence of two by suppos- 
ing it was an exceptional process of development; but 
it is more difficult to explain how the epiphysis should 
have found its way into the lower or distal portion of 
the external lateral ligament, where he correctly states 
that it is situated. The supposed, original seat is 
covered in by perfectly formed lamellated tissue, and underneath the situation 
in which the ossicula are found is a deep fossa fitted exactly to receive them. 




Supposed fracture of 
the entire external epi- 
conclvle. 



§ 10. Fractures of the Internal Condyle. (Trochlea, Chaussier and 
Malgaigne. Internal Oblique Trochlear Fracture, Denuce.) 

According to the nomenclature w T hich I have adopted, those fractures 
alone which involve the joint can be so designated. They are those 
fractures which, commencing outside of the joint above the base of the 
epicondyle, extend downward and outward through the articular surface 
of the bone ; the condylar fragment carrying with itself more or less of 
the trochlea, in most cases passing through the olecranon fossa, the ante- 
rior fossa, and the groove of the trochlea. 

I have a record of twenty examples of this fracture seen by myself, while the 
number of fractures of the external condyle recorded by me is twenty-nine ; 
this difference in frequency being slight, but a little in favor of the external 
condyle. 

Causes. — It has already been stated that fractures of the internal con- 
dyle, as well as fractures of the epicondyle, belong almost exclusively to 
infancy and childhood, only two instances having come under my notice 
after the eighteenth year of life. I have seen no instance which could 
be traced to any other cause than a direct blow, such as a fall upon the 
elbow, the force of the concussion being received directly upon the 
elbow. 

M. Pingaud 1 thinks that even in this case the force applied acts indirectly, 
since it is applied usually to the posterior and internal surface of the olecranon 



1 Pingaud, Art. Coude. Die. Encye. des Sci. Med., prem. ser. t. 21, p. 612. 



256 FRACTURES OF THE HUMERUS. 

process ; and that the condyle yields to the pressure of the crest of the sigmoid 
cavity of the ulna, supplemented by the tension of the muscles and ligaments 
attached to the inner condyle. 

Line of Fracture, Displacement, Symptoms. — The direction of the 
line of fracture is tolerably uniform ; commencing, at or near the centre 
of the trochlea, it extends obliquely inward through the coronoid and 
olecranon fossae, and terminates about one-quarter or half an inch above 
the internal epicondyle. Displacement of the lower fragment can take 
place only in a direction upward, backward, forward, and inward (to the 
ulnar side). The fragment cannot be carried downward, in the direction 
of the hand, nor outward, in the direction of the radius, unless the radius 
also is broken or dislocated. 

The most common form of displacement is upward and backward, and 
perhaps, at the same time, a little inward ; the ulna remaining attached 
to the lower fragment, and following its movements. 

I have seen one instance in which the fragment was carried directly downward 
toward the hand, but this action was originally complicated with a dislocation 
of the radius backward. The dislocation was immediately reduced. Five years 
after, when the man was twenty-three years old, I found the condyle displaced 
downward and forward about half an inch, so that when the forearm was extended 
it became strikingly deflected to the radial side. 

The Symptoms which characterize this fracture are crepitus, almost 
always easily detected ; mobility of the fragment, discovered especially 
by seizing upon the epicondyle, or by flexing and extending the arm ; 
displacement of the smaller fragment and a projection of the olecranon 
process, this latter being very marked when the forearm is extended upon 
the arm, but almost completely disappearing when the elbow is bent ; 
projection of the lower end of the humerus in front when the arm is 
extended ; the humerus shortened when measured along its ulnar side, 
from the internal epicondyle ; the breadth of the humerus through its 
condyles generally increased slightly, sometimes half an inch or more ; 
if the lesser fragment is carried upward, it will also be found that when 
the limb is extended, the forearm will be deflected to the ulnar side. 

Sir Astley Cooper remarks that it is frequently mistaken for a dislocation; 
and Markoe, of New York, has shown that it is, in fact, frequently complicated 
with a dislocation of the head of the radius backward; indeed, he expresses a 
belief that this dislocation of the radius seldom or never occurs without a fracture 
of the internal condyle. 1 

Prognosis. — It is probable that in a majority of cases no permanent dis- 
placement exists ; although the irregularity of the bony deposits around 
the base of the condyle, which generally may be easily felt, would lead to 
a contrary opinion. The fact that the lower fragment usually follows 
the motions of the olecranon, renders its replacement and retention com- 
paratively easy, unless some complication exists. It is not from displace- 
ment, therefore, so much as from permanent muscular, and especially bony 
ankylosis, that serious maiming so often results. Under any treatment 

1 Markoe, New York Journ. of Med., May, 1855, p. 382, second series, vol. xiv. Also 
paper read before N. Y. Surg. Soc., May, 1880. 



FRACTUKES OF THE INTERNAL CONDYLE. 



257 



bony ankylosis will sometimes ensue, and under improper treatment it is 
almost inevitable. 



[Powers/ of New York, reports twelve cases; nine perfectly recovered their 
functions ; one had 5° short of complete extension ; none had deformity.] 

Poinsot says, that of five cases reported by Senftleben, only one recovered 
without ankylosis. In one case where ankylosis re- 
sulted, the operation of resection of the elbow termi- Fig. 129. 
nated fatally. 

Treatment.— The arm must be immediately 
flexed to nearly or quite a right angle, when, 
without much manipulation, the fragments will 
be made to resume their place. A gutta-percha, 
or felt, right-angled splint, such as I have already 
directed for fractures occurring just above the 
condyles, well and carefully cushioned, may now 
be applied/ and secured by rollers. Suitable pads 
must also aid the splint and roller, in keeping the 
fragments in place. 



Fig. 128. 





Fracture of internal condyle. 



Position of the arm in 
carrying a weight. 



Markoe prefers keeping the forearm in a position about ten degrees short of a 
right angle, believing that, in this position, the ulna itself will act as a splint, 
and, by its support on the uninjured portion of the trochlea, hold in its place 
the broken condyle. Very properly, also, he prefers to lay the angular splint, 
made of tin, and fitted to the arm and forearm, upon the back of the limb, instead 
of upon the front or sides. If it is upon the inside, it covers the broken condyle, 
and we are unable to know so well its position ; if upon either side, it is apt to 
press injuriously upon the epicondyles ; and if it is in front, the fragments can- 
not be so well adjusted or supported. Upon this point, however, surgeons are 
not very well agreed, and no doubt more will depend upon the care with which 
the splint is applied than upon the surface against which it is laid. 

[A fact of much importance in the treatment of fractures of the condyles 
relates to the preservation of the normal angle of the forearm with the arm, 



1 Med. Record, Dec. 22, 1888. 
17 



258 



FRACTURES OF THE HUMERUS. 



which gives to the entire limb its " carrying function." This angle is such as 
to give an outward position of the hand when carrying a weight, the elbow rest- 
ing naturally on the thigh. This angle may be lost either by the ascent of the 
internal condyle, or by the descent of the external condyle, and constitutes, in 
the opinion of Dr. Allis, 1 of Philadelphia, the usual deformity after fractures of 
the condyles. To prevent or overcome this displacement, which Dr. Allis 
attributes in part to the flexed elbow and the bandages and splints ordinarily 
used, he places the whole limb in a straight position. The radius and ulna 
at the elbow-joint then tend to bring the internal condyle into position, and 

Fig. 130. 




Deformity after fracture of the lower end of the humerus. (Allis.) 

retain it there, the internal lateral ligament attached to the condyle and ulna 
aiding much to effect this result. The dressings are now applied, bearing in mind 
that " the perfection of the cure will depend wholly upon the natural position 
assumed by the limb while the dressing is applied." He advises that the patient 
be placed on his back, and both arms stripped, in order that the sound arm may 
be a guide in fixing the final position of the injured arm. The well arm is to 
be placed in a supine position, with the thumb looking outward, and the injured 
arm is to be placed in the same position. The forearm of the injured limb must 
form the same obtuse angle with the arm at the elbow as is noticed in the well 
arm. In that position, constantly maintained, the dressings are to be applied, 
and, if plastic, allowed to become firm. Dr. Allis prefers immovable dressings 
or a moulded splint. He applies a temporary dressing for a week, the patient 
being in a recumbent position ; then he proceeds to the permanent dressing as 
follows : 1. An envelope of cotton, an inch thick, extends from the shoulder to 
the wrist, thickest at the bend of the arm ; 2. A layer of bandages, applied suf- 
ficiently tight to compress the cotton and afford support ; 3. The stiffening mate- 
rial selected — starch, plaster-of-Paris, etc. — is rubbed in, and a second and third 
layer of bandage is applied in the same way. The arm is kept in an easy position 
until the dressing is perfectly hard. He gives a simpler form of dressing as a 
substitute: Envelop the arm with cotton and then apply a single covering of 
bandage; cover the w r hole of this with adhesive plaster; this dressing maybe 
applied from first to last ; it has this advantage, that it permits the patient to 
flex the joint a little.] 

Considerable swelling is almost certain to follow, and no surgeon ought 
to hazard the chances of vesications, ulcerations, etc., by neglecting to 
open or completely remove the dressings every day. Within seven days, 

1 Trans. Med. Soc. of Pennsylvania, vol. xiii. part ii. 



FKACTURES OF THE EXTERNAL CONDYLE. 259 

and perhaps earlier, passive motion must be commenced, and persever- 
ingly employed from day to day until the cure is accomplished ; indeed, 
in many cases it is better not to resume the use of splints after this period ; 
for, although at this time no bony union has taken place, yet the effu- 
sions have somewhat steadied the fragments, and the danger of displace- 
ment is lessened, while the prevention of ankylosis demands very early 
and continued motion. 

[The liability to excessive swelling, vesications, etc., occurs only after severe 
injuries, and during the first week. The patient should, at first, remain in a 
recumbent position with light dressings. When this danger is passed the per- 
manent dressing should be applied, and not removed until union has taken 
place, unless there are indications that it is doing harm. Constant efforts at pas- 
sive motion will prove injurious, unless performed by most skilful hands. The 
better rule is to apply the permanent dressing, as recommended above, and when 
union is complete restore action to the joint by passive motion and voluntary 
efforts of the patient, combined with the use of hot fomentations. The liability 
to permanent ankylosis under this course of treatment is slight. If the fracture 
is treated with the limb in a straight position, as described by Allis, and anky- 
losis is apprehended, great care must be taken to secure a flexed position of the 
forearm ; but, unless the ankylosis is due to displacement or callus, the motions 
of the joint are rapidly regained by gymnastic exercises.] 

When the fracture is compound, or otherwise complicated, these simple 
rules will seldom be found applicable ; indeed, fractures attended with 
no such complications will occasionally be found difficult to reduce, or to 
maintain in position after reduction. 

§ 11. Fractures of the External Condyle. 

It is necessary again to call attention to the fact that the author recog- 
nizes no fractures as fractures of the condyles, either external or internal, 
which do not enter the joint. All not included in this definition, and 
occurring in these regions, are epicondylar fractures or diastases. 

Causes. — All the fractures (29) of the external condyle, of which I 
have a record, occurred in children under fifteen years of age, except 
two; one, in which a w^oman, eighty-eight years of age, fell upon her 
elbow when intoxicated, breaking off the outer condyle. In a large 
majority of these cases the patients themselves have affirmed, and the 
surface of the skin has furnished conclusive evidence, that the fracture 
was produced by a direct blow, generally by a fall upon the elbow. 

Line of Fracture, Displacement, and Symptoms. — The direction of 
the fracture is generally such that, commencing at or just within the 
capitellum, or articulating surface upon which the radius is received, it 
terminates above and to the outer side of the external condyle ; or, com- 
mencing at the middle of the trochlea, it passes through the olecranon 
fossa and terminates above the condyle, externally. 

It is quite probable that in the latter case the force which occasioned the 
fracture has been applied directly to the olecranon, and only indirectly to the 
condyle, as suggested by Pingaud ; but this theory of mechanism could not apply 
to the first class of cases, or those in which the line of fracture is through or just 
within the capitellum, and which, I think, is the most common. It is in these 
cases especially, the line of separation being more superficial, that the fragment 



260 FKACTURES OF THE HUMERUS. 

is liable to become displaced backward, forward, or outward ; generally, I have 
found it displaced a little outward, sufficiently to increase manifestly the breadth 
of the condyles, or it has been carried backward ; once slightly forward ; it is 
also, in some cases, carried upward in a small degree, although the action of the 
supinators and extensors would seem to render a downward displacement more 
common. These displacements are usually not considerable, and in a few cases 
there is none at all. Whatever may be the direction or degree in which the 
fragment is moved, the head of the radius is found almost always to accompany 
it; but in the case which I am about to relate, the head of the radius became 
completely separated from the condyle. 

F. K., aet. eleven years, fell from a load of hay, and he is confident that he 
struck the ground with the back of his elbow. Six hours after the accident the 
arm was much swollen, and the external condyle could not be distinctly felt; 
but when pressure was made directly upon it, crepitus and motion became mani- 
fest. The head of the radius was at the same time dislocated backward, and 
separated entirely from the condyle, its smooth, button-like head being very 
prominent. It is difficult to conceive how a blow from behind should leave the 
head of the radius dislocated backward, or how the radius could have separated 
from the broken condyle ; but as the examination was repeated several times, 
and while the patient was under the influence of ether, I have no doubt of the 
fact. Several other surgeons who were present concurred with me in opinion 
fully. While prosecuting the examination, I reduced the dislocation of the 
radius, but it would not remain in place a moment when pressure or support 
was removed. The lad recovered with a very useful arm, the motions of flexion 
and extension, with pronation and supination, after the lapse of a year, being 
nearly as complete as before the accident, the radius remaining unreduced. 

Sometimes it will be noticed that while the portion of the condyle 
which is attached to the radius falls backward, its upper and broken 
extremity pitches forward ; and this attitude it is especially prone to 

Fig. 131. Fig. 132. 








Displc 

cocternal Wk'< ; }' %' 
condyle Ljs^^ 

Fracture of the external condyle through Displaced, external condyle with dislocation 
the capitellum. of radius and ulna. (Bryant.) 

assume when the forearm is extended. It is even possible, when the 
fracture traverses the trochlea, for the ulna also to become displaced 
backward along with the radius and the lesser fragment. (Fig. 132.) 
Crepitus, which is usually very distinct, is most easily obtained by rotat- 
ing the radius, or by seizing upon the condyle with the thumb and fingers, 
and moving it backward and forward. 



FRACTURES OF THE EXTERNAL CONDYLE. 261 

[Bryant, 1 of London, resected the elbow-joint of a boy, set. 10, six weeks after 
the injury, who fell upon his hand with his arm extended. The external con- 
dyle had been broken and vertically displaced; the head of the radius and ulna 
were both displaced inward and well locked by processes of bone, the coronoid 
process was in contact with the outer portion of the internal condyle, and its 
outer edge with the inner margin of the trochlear surface of the humerus. The 
head of the radius rotated on the displaced inner half of the articular facet of 
the humerus, with its outer edge in contact with the displaced external condyle.] 

Prognosis. — Ordinarily, this fragment unites promptly, and by the in- 
terposition of a bony callus ; but in five cases, I have noticed that either 
no union has occurred, or the union has been accomplished only through 
the medium of fibrous structures, and the fragment continued afterward 
to move with the radius. As a consequence, probably, of the displace- 
ment of the lesser fragment upward, the forearm, when straightened, is 
occasionally found deflected to the radial side. The surgeon must not, 
however, confound the deflection which is natural, and which is greater 
in children than in adults, with the unnatural radial inclination which is 
occasioned sometimes by this accident. 

I have met with this phenomenon three times in children under three years 
of age, in one of which I could not discover that the condyle was carried toward 
the shoulder, but only outward ; in each of the other cases the fragment had 
united by ligament. The following is one of the examples referred to : 

A girl, set. 3, fell and broke the external condyle of the left humerus, the 
fracture extending freely into the joint ; crepitus distinct ; forearm slightly 
flexed ; prone. Lesser fragment displaced outward and a little backward, carry- 
ing with it the radius. On the second day I was dismissed on account of the 
unfavorable prognosis which I gave, or rather because I refused to guarantee a 
perfect limb, and an empiric was employed. Several months after the accident 
the father brought her to me for examination. There was no ankylosis, but 
the lesser fragment had never united, unless by ligament, moving freely with 
the head of the radius. When the forearm was straightened upon the arm, it 
fell strongly to the radial side, but resumed its natural relation again when the 
elbow was flexed. Two other examples are reported at length, in the second 
part of my Report on Deformities After Fractures. In one other example, how- 
ever, mentioned also in my report, the deflection was to the opposite side. I 
examined the lad one year after the accident, he being then five years old, and 
I found the external condyle very prominent and firmly united, but not appa- 
rently displaced in any direction except outward. The radius and ulna had 
evidently suffered a diastasis at their upper ends, but all of the motions of the 
joint were free and perfect. 

In more than half of the cases of fracture of this condyle some degree 
of ankylosis has resulted, lasting at least several months. I have seen 
it remaining after a lapse of from one to twenty years, but generally 
it gradually diminishes, and, in a majority of cases, completely disappears 
after a few years. 

Treatment. — Generally, the forearm ought to be flexed upon the arm, 
especially with a view to overcome the usual tendency in the upper end 
of the lower fragment to pitch forward, and which form of displacement 
is greatly increased by straightening the arm. 

A remarkable exception to this rule, and one of two which I have seen, must 
be mentioned. James Cronyn, aged 6, was brought to me in March, 1857, 

1 Practice of Surgery, 4th edition, 1885. 



262 FRACTUKES OF THE HUMERUS. 

having, a few minutes before, fallen from a height of four or five feet to the 
ground. His father said the elbow had been broken at the same point two years 
before, and from that time had remained stiffand crooked. I found the external 
condyle broken off, and, with the head of the radius, carried backward. This 
was the position which it occupied constantly, although it was easily restored 
and maintained in position when the arm was straight, but not by any possible 
means when the elbow was flexed. I dressed the arm, therefore, in an extended 
position, with a long felt splint, and the fragments remained well in place until 
a cure was accomplished. 

It is especially deserving of notice that, in the five cases in which I 
have observed bony union to fail, and the fragments to continue movable, 
the motions of the elbow-joint have, in a very short time, been completely 
restored. This fact must abate our apprehensions of the supposed evil 
results of non-union in the case of fracture now under consideration. 

The opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris in his 
Eeport on Surgery, is as follows : 

" In the treatment of fractures of the condyles of the os humeri, a course is 
usually recommended which he believes to be hurtful, inasmuch as it favors the 
worst consequences of the injury, namely, loss of motion in the joint. By this 
mode of treatment, the fractured piece becomes sufficiently fixed to create partial 
ankylosis; and there is so much pain afterward in the proposed passive move- 
ments as to cause the omission of these measures until permanent stiffness takes 
place. The proper course in the management of these accidents, he conceives 
to be — 1st. To apply no splints, but in the earlier days to make use of the proper 
means to prevent inflammation. 2d. To accustom the patient to early and daily 
movements of flexion and extension. 3d. When the action of the joint becomes 
limited, to overcome the resistance by force, and repeat it daily until the ten- 
dency of the joints to stiffen ceases." 1 

My respect for the distinguished surgeon whose opinion is here given does 
not permit me to question the correctness of his practice; but I cannot avoid a 
belief that his language does not convey a precise idea of his views. If he 
intends to say that he would move the joint freely when it is suffering from 
acute inflammation, and when motion occasions great pain, I must protest 
against the practice as likely to do vastly more harm than good in any case ; 
but if he would move the joint from the first, when the inflammation and swell- 
ing are trivial, and when it occasions only a moderate amount of pain, then his 
views are just, and his practice worthy of imitation. 



§ 12. Fractures of the Articular Processes of the Lower End of the 
Humerus ; wholly within the Capsule. 

Three examples illustrating this variety of fracture have been referred to by 
Stimson. 2 The first was seen by Laugier, 3 in the person of a girl seventeen 
years old, who had fallen upon her hand. It was not followed by swelling or 
by effusion within the joint. Laugier considered it a fracture of the trochlea 
alone. The treatment consisted in rest, the forearm being slightly flexed and 
pronated. In a few weeks recovery took place, with complete restoration of the 
functions of the arm. 

The second case is from Gurlt, 4 a museum specimen, without history. It. is 
an adult bone. The trochlea and capitellum are broken off and displaced for- 
ward and upward, and have reunited with the bone above the coronoid fossa; 
the articular surfaces being still covered with cartilage. 

1 Transactions of the American Medical Association, vol. i. p. 174. 

2 Stimson, Treatise on Fractures, p. 413. 

3 Laugier, Arch. Gen. de Med., 1853, v. i. p. 45. 

4 Gurlt, Knochenbr iichen, vol. ii. p. 801. 



FRACTURES OF THE RADIUS. 263 

The third 1 is that of a woman, set. 67, who having received an injury upon 
her elbow, the surgeon diagnosticated a fracture of the neck of the radius : but 
the patient having died four years Jater, the capitellum was found broken off 
and displaced ; having reunited with its upper border resting in the radial 
depression (fovea minor). The head of the radius was not broken. 

The same difficulties present themselves here as in the supposed examples of 
intracapsular fractures of the head of the humerus. In the clinical example 
related by Laugier, the exact line could not have been absolutely determined. 
And this difficulty is illustrated by the third case, in which the clinical diagnosis 
was greatly at fault. The third case also, where an autopsy was made after four 
years, can only be regarded as furnishing conclusive evidence that the capitellum 
was broken ; inasmuch as the changes in its form and size, caused by absorption, 
as we have seen, happens in intracapsular fractures of both the heads of the 
humerus and femur, must render it difficult to say that the line of fracture was 
not outside of the capsule. The second case was a museum specimen, unac- 
companied with a history, and for the same reason there can be no conclusive 
evidence that it was intra-articular. Whenever we find a recent accident, in 
which the autopsy shall show that the line of fracture was wholly within the 
capsule, the testimony will be conclusive. At present this kind of testimony is 
wanting. 



CHAPTEE XXII. 



FRACTURES OF THE RADIUS. 

Fractures of the radius occur more frequently than of any other 
bone of the skeleton, except perhaps the clavicle. The location of these 
fractures may be seen in the following analysis : 

Of 127 fractures of the radius which have been recorded by me, not including 
gunshot fractures, or fractures demanding immediate amputation, 3 belonged to 
the upper third, 10 to the middle third, and 114 to the lower third. Of those 
belonging to the lower third 7 were through the shaft, more than two inches 
above the lower end; 2 were fractures of the styloid processes; and the re- 
mainder, 105, were Colles's fractures. 5 were compound, and 122 simple. 69 are 
reported as occurring in males, and 58 in females; 61 as having occurred in the 
left arm, and 41 in the right. 

Fractures of the Head. — Most of the fractures of the head of the 
radius which have been satisfactorily demonstrated, were longitudinal or 
nearly so. 

In Dr. Mutter's collection are two specimens of fracture of the outer half of 
the head of the radius. In one the small fragment is slightly displaced down- 
ward in the direction of the axis of the bone ; and in the other the fragment is 
thrown outward, or to the radial side. Both are firmly united in this position. 
Stimson says, in his treatise on Fractures, that he met with two cases, in one 
of which the injury was the result of a direct blow, and the other was accom- 
panied with a dislocation of the radius and ulna backward. In both cases he 
practised resection, but he does not say with what result. He has seen, also, 
one other case treated by Dr. Townsend, of Bellevue Hospital, in which one 
year after the accident the fragment remained movable, but the motions of the 
joint were completely restored. 

1 Gurlt, op. cit„ vol. ii. p. 831. 



264 



FRACTURES OF THE RADIUS, 



Bruns 1 has collected twenty-two cases of longitudinal fracture of the head, 
recorded or observed by Hodges, 2 Verneuil, 3 Flower, 4 Gross, 5 Gurlt, 6 Weichsel- 
baum, 7 Lesser, 8 Hiiter, 9 and himself, respectively. Malgaigne has also men- 
tioned one. 10 

[Many additional cases have been reported during the last few years.] 

According to Bruns, this fracture " may be incomplete, and then the 
fissure may be single or multiple. When it is complete, a fragment of 



Fig. li 



Fig. 1?A 



for 



, 




Gross's specimen. 

the anterior border is generally found separated 
from the bone ; at times, then, the fracture is 
entirely intra-articular, and the fragment of bone 
is loose in the interior of the joint ; at others it 
extends beyond the articulation, and the fragment 
may be held in place by the annular ligament. 
Fracture of the head of the radius may be isolated 
(five times out of twenty-two cases), but more often 
it is complicated with lesions of the neighboring 
bones (four times with fracture of the external con- 
dyle, three times with fracture of the olecranon, of 
the coronoid process, and of the neck of the radius, 
twice with fracture of the olecranon and the 
coronoid process, twice with a fracture of the 
coronoid process and a dislocation of the forearm, 
once with fracture of the shafts of the humerus 
and ulna and dislocation of the radius forward.) 

As may be seen, the most frequent complication is fracture of the 

coronoid process. 

i Bruns, des frak. des radius kopfchens, Centralblatt fur Chir., 1880, No. 22, pp. 353-358. 

2 Hodges. Bost. Med. and Surg. Journ., Dec. 6, 1866, p. 383, and 1877, p. 65. 

3 Verneuil, Jajavay, Frac. des Artie, These d'agreg., Paris, 1851. 

* Flower, Holmes's Surg., vol. ii. 2d ed. p. 791. 5 Gross's Surg., 1859, p. 181. 

6 Gurlt, Handbuch der Lehre von den Knoch., 2d theil, Berlin, 1865, p. 810. 

7 Weichselbaum, Virchow's Arch , Bd. 57, p. 127. 

8 Lesser, Deutsche Zeitschrift fiir Chir., Bd. 1, p. 292. 

9 Hiiter. Verhandl. der Deutschen Gesellschaft fiir Chir., V. Kongress, 1876, p. 39. 
10 Malgaigne, Poinsot, op. cit ., p. 332 et seq. 



Fracture of head of ra- 
dius. (Mutter's Collection 
Specimen A, ISTo. 105.) 



FRACTURES OF THE RADIUS. 265 

" Although fracture of the head of the radius is sometimes produced 
by a direct injury, it is most frequently the result of an indirect cause, 
such as a fall upon the hand, the arm being extended; in this position, 
indeed, the external condyle comes in contact only with the anterior part 
of the head of the radius. This fracture sometimes occurs when the 
forearm is in a state of extreme flexion ; in such case it is probably the 
result of violent contact of the anterior border of the head with the anterior 
surface of the humerus." — Poinsot. 

[Gross illustrates a fracture of the head of the radius in his collection in which 
a portion of the head has been chipped off and permanently united to the con- 
tiguous border of the coronoid process of the ulna. (Fig. 134.)] 

The diagnosis of this accident is in many cases difficult. Occasion- 
ally, when the fracture is complete, a movable fragment may be recog- 
nized, with crepitus ; and in other cases its existence may, perhaps, be 
inferred from the increased breadth of the head of the radius, the condi- 
tion simulating a partial dislocation forward. 

[Powers, 1 of New York, who analyzed fourteen cases, states that the diagnosis 
must rest on the recognition of the movable fragment of bone; crepitus about 
the joint he regards as too deceptive.] 

Bruns says that out of seven observations where the results could be estab- 
lished, three times bony consolidation occurred, once the fragment united by 
callus to the coronoid process, and three times the isolated fragment finally 
became a truly foreign body in the articulation. Hiiter, in his case, was obliged 
to resort to arthrotomy in order to extract this foreign body of a new kind. 
Kofmohl 2 affirms that a longitudinal fracture of the head of the radius is more 
common in childhood than in adult life, he having met with seventeen cases in 
a total of fifty-two fractures of the forearm, and twelve of the subjects were 
from one to four years of age. He states, moreover, that it is caused most often 
by lifting the child by the arms ; that the pain accompanying the accident is 
usually felt at the wrist, and that the results are of the simplest kind, the func- 
tions of the limb being completely restored in from three to four weeks. In my 
opinion, these statements of Kofmohl ought to be received with much hesitation. 

The treatment of this fracture, in case it be recognized, ought to be 
directed chiefly, as in most other fractures involving joints, to the pre- 
vention of ankylosis, by careful but persistent motion of the joint by 
flexion and rotation. The result might be a fibrous union, or perhaps 
non-union and necrosis of the fragment ; but even this latter result would 
be no more serious than a permanent ankylosis. 

[The persistent motion recommended will, in the practice of most surgeons, 
result in non-union, which would be an unfavorable result. The more con- 
sistent course of treatment would be complete rest to the injured parts until 
union is perfected, and subsequent motion, both passive and active.] 

It is probable, however, that in most cases a more or less flexed posi- 
tion of the arm, Avith supination, will insure the most satisfactory results. 
In case ankylosis were to result, the flexed position, at a right angle, 
would give the most useful arm. 

b. Fractures of the Neck. — Fracture of the neck of the radius, as a 
simple accident, uncomplicated with any other fracture or dislocation, is 

1 Med. Record, Feb. 25, 1888. 

2 Kofmohl, Ueber den intrakap., Brueh des radius, etc., Wiener med. Presse, No. 12, 
p. 369, 1879. 



266 



FRACTURES OF THE RADIUS. 



Fig. 135. 



exceedingly rare ; yet, owing to the depth of the superincumbent mass 
of muscles, and the difficulty of determining, where so many bones and 
processes approach each other, precisely from what point the crepitus, if 
any is found, proceeds, surgeons have often been deceived. 

The case reported by Dr. Markoe to the New York Pathological Society will 
serve to illustrate the same point ; the signs of a fracture of the radius at its 
neck were such as to deceive that experienced surgeon, yet the autopsy disclosed 
the fact that it was a dislocation of the head of the radius forward, with a frac- 
ture of the ulna. 

I have seen no specimen obtained from the cadaver, except the doubtful one 
contained in Dr. Watt's cabinet, and the specimen owned by the late Dr. Mutter, 
of Philadelphia, of which he has kindly furnished me the following descrip- 
tion : "History unknown. The line of fracture 
seems to have passed through the neck of the left 
radius, just at the upper extremity of the bicipital 
protuberance. Union with deformity has resulted. 
Owing to the fracture having taken place within 
the insertion of the biceps, that muscle appears to 
have drawn forward and upward the lower end of 
the short upper fragment. In consequence of this 
movement, the articulating facet of the head of 
the radius is tilted backward, so as no longer to 
be in contact with the humerus. As a secondary 
consequence, the anterior edge of the head of the 
radius rests permanently against the articulating 
surface of the humerus. At this new point of 
contact a new surface of articulation is seen to 
have been formed, while the original articulating 
facet is directed backward, and lies at right 
angles to the one of more recent formation. At 
the inner edge of the new articulation of the 
head of the radius with the humerus, contact 
with the ulna has developed another surface of 
articulation. The upper and lower fragments are 
united at an angle, and the radius does not appear 
to have lost in length." 

Velpeau has once demonstrated the existence of 
this fracture in a dissection, but the fracture was 
accompanied with a fracture also of the coronoid 
process ; and Berard obtained possession of a simi- 
lar specimen. Malgaigne affirms, with his usual 
frankness, that although 'he has occasionally be- 
lieved that he had met with it, the autopsy, when- 
ever it has been obtained, has shown that it was 
rather a subluxation than a fracture. 




Fracture of nee 
(Mutter's cabinet.) 
articulating facet, 
ticulating facet. < 
fragments. 



of radius. 

a. Original 

b. New ar- 

Projecting 



Diagnosis. — The presence of what appear 
to be the rational diagnostic signs has com- 
pelled me to record one case as an uncompli- 
cated fracture of the neck of the radius, and two others as fractures at 
this point accompanied either with a fracture of the humerus or a dislo- 
cation of the ulna. I am prepared to admit that some doubt remains in 
my own mind as to whether in either case the fact was. clearly ascer- 
tained ; nor do I think, speaking only of the simple fracture, that it will 
ever be safe to declare positively that we have before us this accident. 

Nothing, perhaps, could more fully illustrate the difficulty of diagnosis in the 
case of injuries received in the neighborhood of the head or neck of the radius 



FRACTURES OF THE RADIUS. 267 

than the testimony given in the case of Noyes vs. Allen, tried in the Supreme 
Court at Cambridge, January, 1856, before Judge Bigelow. Mr. Noyes injured 
his elbow, January 7, 1854, and Dr. Allen, who was called immediately, believed 
that the ligaments of the joint had been torn, but that no bones were broken or 
displaced. On the following morning he was dismissed, and Mr. Noyes went 
home. Three weeks later it was seen by Dr. Dow, who also thought there was 
no fracture. About eight weeks after the accident a physician examined the 
arm, and delared the neck of the radius broken, and the fragments displaced ; 
and when the case was finally brought to trial he testified still that such was 
certainly the fact ; and five other physicians, not one of whom, however, we are 
told, was a member of the State Medical Society, testified positively that the 
radius was broken at its neck, producing a bony protuberance; that such an 
injury only could account for the symptoms manifested at the time of the acci- 
dent, and that no other fractures or injuries of the joint could explain so well 
the present appearances of the arm. While, on the part of the defence, six of 
the most intelligent medical gentlemen of the State, Drs. Kimbal and Hunting- 
ton, of Lowell, and Drs. Townsend, Lewis, Clark, and Gay, of Boston, testified 
that the head and neck of the radius were not displaced, nor was there any evi- 
dence that this bone had ever been broken. There is every reason to believe 
that these latter gentlemen were correct; yet it is to be presumed that the 
gentlemen who first testified were not without some grounds for their opinions 
so confidently expressed. The case was given to the jury after a trial of five 
days, which promptly returned a verdict for the defendant. 1 

When the fracture occurs, the upper end of the lower fragment will 
probably be carried forward by the action of that portion of the biceps 
which has its insertion into the tubercle ; and the displacement in this 
direction must necessarily be increased in proportion as the arm is 
straightened. In the cabinet specimen belonging to Dr. Mutter (Fig. 
135), the line of fracture commencing in the neck, has terminated in the 
tubercle ; consequently the biceps, having still some attachment to the 
upper fragment as well as the lower, has drawn them both forward. The 
same anterior displacement I have noticed in all of the supposed living 
examples, but whether both fragments or only one had suffered displace- 
ment I am unable to say. 

A girl, set. 11, fell from a tree, and injured her right arm. Her surgeon, who 
regarded it as a fracture of the neck of the radius, reduced the fragments, and 
placed the forearm at a right angle with the arm. On the twenty-eighth day 
all dressings were removed, and the patient was dismissed, the fragments seem- 
ing to be in place. The parents, finding the elbow stiff, now made violent and 
successful efforts to strengthen the arm. Fifteen months after the accident, the 
child was brought to me. There was at this time a bony projection in front, 
opposite the neck of the radius, which I believed to be the point of fracture. 
The hand was forcibly pronated, and she had only a limited amount of motion 
at the elbow-joint. The ankylosis was probably due to inflammation directly 
resulting from the severe contusion ; but it is quite probable that the forward 
displacement of the fragments was alone due to the too early and too violent 
attempts to straighten the arm ; at least, this was the explanation which I ven- 
tured to give to the parents at the time. 

The second case occurred in a lad eight years old. His parents brought him 
to me ten weeks after the injury was received, and I then found the forearm 
bent to a right angle with the arm, and ankylosed at the elbow-joint. The hand 
was also forcibly pronated, and could not be supinated. In front, and opposite 
the neck of the radius, there was a distinct bony projection, which I believed to 
be the point of union of the bony fragments. The external condyle seemed also 
to have been broken. 

1 Amer. Med. Gazette, vol. vii. p. 299. 



268 FRACTURES OF THE RADIUS. 

The third example was seen by me six months after the accident. The upper 
end of the lower, fragment seemed to be displaced forward. There was very- 
little motion at the elbow-joint, and both pronation and supination were com- 
pletely lost. 

Treatment. — Flex the forearm upon the arm, to relax, as completely as 
possible, the biceps, whose advantageous insertion into the tubercle of the 
radius would be certain to produce displacement, unless this position was 
adopted. A single dorsal splint, properly padded, should support the 
forearm, while the surgeon, having placed a compress over the upper end 
of the lower fragment, proceeds to secure the whole with a roller. Espe- 
cial care must also be taken to prevent the forearm from being extended 
before the bony union is fairly consummated, lest the biceps, now firmly 
contracted, should draw the lower fragment forward, as it must inevita- 
bly do while the bony union is imperfect ; an accident which there is 
some reason to believe, occurred in one of the examples which I have 
already cited. If the patient be a child, or if there is any reason to sup- 
pose that these rules will not be faithfully complied with, it would be 
w r ell to secure the arm in this position with a right-angled splint. 

Fractures below the Insertion of the Biceps, and above the Insertion 
of the Pronator Radii Teres. — When the bone is broken anywhere in 
this portion, the action of the pronators upon the upper fragment ceases ; 
while that of the biceps, which is a powerful supinator, continues ; con- 
sequently the upper fragment becomes at once, and completely, rotated 
outward or supinated. Now, if the hand, to which the lower end of the 
radius alone remains attached, should be forcibly pronated, the radius 
will also be rotated inward upon its own axis ; and although it might be 
possible in this condition to bring the broken ends into contact, and a 
bony union, without deformity, might be consummated, yet the power of 
supination must be forever lost ; since the union has been effected while 
the head and upper fragment are already in a state of complete supina- 
tion ; and if such is the fact, it is evident that the whole bone, together 
with the hand, will be incapable of any further supination. 

It is not, indeed, the practice with any surgeons, as far as I know, to 
treat this fracture with the hand placed in a position of extreme prona- 
tion ; but the case has been supposed for the purpose of rendering the 
argument more intelligible. The usual practice is to place the forearm 
and hand in a position midway between supination and pronation, and 
then to lay it across the body at a right angle with the arm ; but it is 
plain that the same objection, differing only in degree, will apply to this 
position as to that of pronation. The axes of the two fragments are not 
made to correspond, since, while the lower fragment is only half rotated 
outward, the upper fragment is completely, and the result of the union 
must be the loss of one-half the power of supination in the hand. 

It is only, then, by complete supination of the hand during treatment 
that this difficulty can be avoided, and I have no doubt that we ought to 
adopt this plan, whenever it is practicable to do so, or whenever we are 
not hindered by serious obstacles ; and the only obstacle which occurs 
to me as likely to interpose itself, is the practical one which most sur- 
geons must have experienced in treating all injuries of the forearm, 
whether fractures or only severe contusions of the muscles, etc., namely, 



FRACTUKES OF THE RADIUS 



269 



the constant and almost uncontrollable tendency of the hand to assume 
the prone or semi-prone position. This is due, no doubt, to the great 
preponderance of power in the pronators : and such is the resistance 
which they afford to supination that it is often quite impossible to lay 
the hand upon its back while the forearm is across the body, and, if 
accomplished, the position generally becomes in a few hours so painful 
as to be intolerable. By extending the arm, however, and laying it 
upon a pillow, the hand will be found again to rest easily upon its back, 
because in this way we avail ourselves of the outward rotation of the 
humerus at the shoulder-joint. 

Dr. X. C. Scott, formerly Eesident Surgeon to the Brooklyn City Hospital, in 
his inaugural thesis, has discussed very fully the advantages of this position in 

Fig. 136. 




Scott's apparatus for fracture of the forearm. 



many fractures of the forearm, and he has devised a very ingenious mode of 
securing the limb after supination is effected, adding also a moderate amount of 
extension by adhesive plasters and elastic bands. 

Fractures of the Shaft. — It has been already stated that of the whole 
number of fractures of this bone recorded by me, amounting in all to 
127, only 10 belonged to the middle third ; an observation which is in 
striking contrast with the remark of Chelius, that it is broken most 
frequently in its middle. If the fragments are completely separated in 
the middle third, the lower end of the upper half is drawn forward by the 
action of the biceps aided by the pronator radii teres, in case the fracture 
is below its insertion ; while the lower fragment is tilted toward the ulna 
by the conjoined action of the supinator radii longus and pronator quad- 
ratus. But as to the direction of the displacement, much will depend 
upon the direction of the force by which the fracture has been occ asioned. 

A laboring man, set. 35, broke the radius near the lower end of the middle 
third. On the same day I replaced the fragments as well as I could in the 
midst of the swelling which had already occurred, and applied two broad and 
well-padded splints, one to the palmar and one to the dorsal surface of the fore- 
arm. On the twenty- eighth day I first discovered that the fragments were pro- 
jecting in front, and I at once proposed to thrust them back by force, but the 



270 FRACTURES OF THE RADIUS. 

patient declined allowing me to do so. I then applied a compress near the 
summit of the projection, but not exactly upon it, lest it should cause ulceration, 
and secured over this a firm splint. At first this seemed to produce a change in 
the fragments, but after a couple of weeks I found there was no improvement, 
and it was discontinued. About six months after the fracture occurred, this 
man had the same arm terribly lacerated in a railroad accident, and I was 

Fig. 137. 




Fracture of the shaft of the radius. (From Gray.) 

obliged to amputate near the shoulder-joint; and I thus obtained the broken 
radius. The bone was firmly united, but with an angle, salient forward, of about 
ten degrees. There was no inclination toward the ulna. My impression is that 
these fragments were never completely replaced, a point which I could not well 
determine at first on account of the rapid effusion. If they had been, I think 
they could have been retained in place with the appliances used. Almost every 
day the limb was examined, and as often as every fourth or fifth day the dress- 
ings were removed and carefully reapplied. And only once did they become so 
loose as not to afford the requisite support, and this at a period too late to have 
occasioned the deformity. 

We ought not to be deceived, and promise too confidently a perfect 
limb, even when but the radius is broken, since we may not always be 
certain that the ends are well replaced, or perhaps they may become dis- 
placed subsequently, and in either case we are not likely to discover the 
deformity until the swelling has subsided, and it is too late to apply the 
remedy. 

In the treatment of fractures of the middle third, the same rules, with 
only slight modifications, will be applicable, as in fractures of both bones. 
Two straight, long, and broad splints must be applied after being care- 
fully padded ; and especial attention should be paid to the tendency of 
the fragments to become displaced forward and toward the ulna through 
the action of both the biceps and the pronator radii teres ; a tendency 
which may in some measure be provided against by flexion of the arm, 
but which must be overcome chiefly by steady and w T ell-adjusted pressure, 
near, but not upon, the ends of the fragments. 

Fractures of the Lower End. — Fractures of the lower third, occurring 
above the line of Colles's fracture, are almost as rare as fractures of the 
middle or upper third. 

I have recorded seven ; one example of which it will be proper to relate : 
G. V., set. 30, was admitted to the Buffalo Hospital with a fracture of the 
right radius about three and a half inches above its lower end. The hand was 
prone, and inclined to the radial side ; while the broken ends of the radius fell 
against the ulna, from which it was found difficult to separate them. The lower 
end of the ulna was prominent, and projecting upon the ulnar margin of the 



FRACTURES OF THE RADIUS. 271 

hand. I was unable completely to separate the fragments of the radius from 
the ulna, by either pressure with my fingers between the bones, or by seizing 
upon them with my thumb and fingers. Having, however, adjusted them as 
well as possible, I flexed the arm, and applied a broad and well-padded splint 
to the palmar surface of the forearm, securing it in place with a paste bandage. 
These dressings were finally removed at the end of four weeks, when I found 
scarcely any displacement or deformity remaining. 

Most of these fractures of the shaft in its lower end, when properly 
treated, result in perfect limbs. In a certain proportion, however, it will 
be found impossible effectually to resist the action of the pronator radii 
teres and of the quaclratus, and the fragments will unite at an angle 
resting against the ulna, and sometimes, by the interposition of inter- 
mediate callus, they will become firmly united to the ulna. Occasionally, 
also, especially where the fracture has been produced by a fall upon the 
hand, and the radio-ulnar ligaments of the wrist have been torn or 
stretched, the lower end of the ulna will be found to project perma- 
nently, and the hand to fall more or less to the radial side. In examples 
of this kind, of which I have seen one or two, the cause and, to some 
degree, the manner of the displacement are such as to entitle them per- 
haps to be regarded as true Colles's fractures ; but we have found it 
convenient to restrict the use of this title to fractures occurring within at 
least one inch and a half of the joint. 

Colles's Fracture. — I have retained the name "Colles's fracture," so 
long in use by English-speaking surgeons, for the reason that it is familiar 
to most of my readers, although it is now well known that Pouteau first 
described this accident. 1 Of the 114 fractures belono-ino; to the lower 
third of the radius, 105 were near the lower end, or within from half 
an inch to one inch and a half from the articular surface ; all, except 
2 styloid fractures, being included in that class known as " Colles's 
fractures," most of which were no doubt true fractures, and probably a 
small proportion separations of the epiphyses. 

[Double Colles's fractures are very rare. Mclntyre, 2 of St. Louis, reports such 
a case. The patient was a man, aged nineteen, who fell from a roof; he recov- 
ered, with good use of both arms. Bryden" reported a similar case occurring in 
a sailor, who fell thirty feet to the deck of a ship.] 

Colles, in his paper on this subject, described the fracture as occur- 
ring always about one inch and a half above the carpal end of the bone; 4 
but Robert Smith, who has carefully examined all of the cabinet speci- 
mens he could find, about twenty-three in number, has never seen the 
line of fracture removed farther than one inch from the lower end of the 
bone, and in several specimens it was within one-quarter of an inch of 
this extremity. Dupuytren has also described the fracture as occurring 
from three to twelve lines above the joint. 

1 Pouteau, (Euvres Posthumes, t. ii. p. 251, 1783; also Xelaton, Chir. Path., t. i. p. 739. 

2 St. Louis Med. aud Surg. Journ., 1885. 
s Brit. Med. Journ., Dec. 8, 1883. 

4 Colles, Ed. Med. and Surg. Journ.. vol. x. p. 182. 1814. 



272 



FKACTUEES OF THE RADIUS. 



M. Trelat 1 thinks that in the fractures of old people the line of separation is 
ordinarily quite at the inferior extremity of the bone. 



Fig. 138. 



Fig. 139. 



Fig. 140. 





Fracture of lower end of 
radius : back view. 



Fracture of lower end of 
radius; side view. 



Contrary to the opinion of Sedillot and Huel, M. 
Voillemier affirms that, instead of being oblique, as 
has generally been supposed, the fracture is almost 
uniformly transverse from the palmar to the dorsal 
surfaces of the bone, and only occasionally slightly 
oblique in its other diameter, or from the radial to 
the ulnar side. I have seen, however, in the museum 
of the College of Physicians of Philadelphia, a 
specimen of this fracture in which the line of frac- 
ture is transverse, from side to side, but very oblique 
from before backward, and from below upward. 
There is also a line of incomplete fracture extending 
into the joint. It is united by bone, with the usual 
displacement backward ; and there are several sim- 
ilar specimens in the New York Hospital museum. 
My own cabinet contains two such examples. It is 
my opinion, therefore, that the direction of the line 
of fracture described by Voillemier is exceptional. 



Bones in an old Colles's 
fracture, showing dorsal 
prominence made by lower 
fragment and carpus, and 
palmar projection caused by 
lower end of the upper frag- 
ment. (Erichsen.) 



The observations of both R. Smith and 
Voillemier have shown, moreover, that the dis- 
placement of the lower fragment is seldom suffi- 
cient to enable it to escape completely from the upper ; and that where, in 
extremely rare instances, and in consequence of extraordinary violence, 
such complete separation does occur, a disruption of those ligaments 
which attach the lower fragment to the ulna occurs also, and the de- 
formity becomes at once very great, so that it no longer presents the 
peculiar features of Colles's fracture, but resembles a dislocation. 



Trelat, Journ. de Med. et de Chir. Prat., Avril, 1877. 



FRACTURES OF THE RADIUS. 2,3 

In Colles's fracture, the lower and outer border of the radius, or its 
styloid apophysis, is swung around or tilted, as it were, upon the ulna ; 
the lower and inner border of the same fragment being retained in place 
by the radio-ulnar and internal lateral ligaments, which do not usually 
suffer a complete disruption, but only a stretching or partial laceration, 
possibly by the triangular ligament or by some of its untorn fibres, and 
by one fasciculus of the anterior annular ligament, which is probably 
seldom torn. The upper or broken margin of the lower fragment, and 
also the ulnar margin, undergo very little displacement ; while the lower 
or articular surface, and the radial margin, are carried backward, up- 
ward, and outward. 

Surgeons have spoken of a falling in of the upper end of the lower fragment 
toward the ulna, as an almost inevitable result of the action of the pronator 
quadratus, and against which tendency they have sought carefully to provide; 
but there is much reason to believe that any considerable degree of displacement 
in this direction is a rare event, and that, when it does exist, it is in consequence 
mostly of the direction of the force which has produced the fracture rather than 
of the action of this muscle, only a few of the fibres of which are usually attached 
to the lower fragment, and, in some instances, when the fracture is within a half 
or quarter of an inch of the articulation, not any. Besides, there is actually in 
these latter cases no interosseous space into which the fragments may fall, and 
its displacement toward the ulna becomes, therefore, impossible. 

Still, however, if one were disposed to speculate upon the condition of these 
parts after the fracture, it might perhaps be easy to persuade ourselves that the 
action of the pronator quadratus upon the upper fragment, whose broken ex- 
tremity was not completely, or at all, disengaged from the lower, would carry 
both fragments together toward the ulna. But whatever might be the result of 
our speculations, still the fact, as proved by specimens, is not generally so; and ■ 
this is not the first time that facts and theories have disagreed. The truth is, 
that it is unusual to find any of the museum specimens of this fracture thus 
united. But they may be found constantly tilted back in the manner I have 
described, occasionally tilted forward, and, still more rarely, slightly displaced 
upon their broken surfaces antero-posteriorly. 

The general absence of internal displacement may find its explanation 
in the direction of the force which generally produces this fracture, in 
the occurrence of the fracture sometimes at a point so low as to render 
its displacement in this direction impossible, and in the breadth of the 
bone, at the seat of the fracture, which does not permit it to fall laterally 
without actually increasing its length ; a circumstance which its secure 
ligamentous attachment to the ulna at its opposite extremities, and its 
complete apposition to the wrist and elbow-joint, do not allow. The 
mistake of those surgeons who have attempted to describe this fracture 
has originated in the appearance presented in nearly all recent fractures 
occurring at this point. The hand falls to the radial side, and seems to 
carry the lower end of the lower fragment with it, while the lower end 
of the ulna becomes unnaturally prominent in front and to the ulnar 
side ; a condition of things which has naturally enough been ascribed to 
the displacement of the upper end of the lower fragment in the direction 
of the interosseous space. But this same radial inclination of the hand, 
and prominence of the ulna, are present frequently when the radius is 
broken at its lower end, and no displacement in any direction has taken 
place ; and I have even observed it in simple sprains of the wrist, and 

18 



274 FRACTURES OF THE RADIUS. 

in the hands of old or feeble persons where all the ligaments have become 
relaxed. 

It is seen, however, in a more marked degree when the bone is actually 
both broken and displaced backward in its usual direction. In short, 
the deformity in question is due, in a large majority of instances, to the 
relaxation, stretching, or more or less disruption of the anterior and pos- 
terior radio-ulnar ligaments, the triangular fibro-cartilages, and the inter- 
nal lateral ligaments; to which, I feel satisfied, we must add the influence 
of the strong and unbroken oblique fasciculus of the anterior carpal liga- 
ment. It is probably due to one or all of these circumstances combined 
that the hand falls to the radial side by a sort of rotatory motion, of 
Avhich the unbroken external lateral ligaments and the strong fasciculus 
of the anterior ligament constitute the axis or centre of motion. For 
this reason, also, because these triangular, internal, and radio-carpal 
ligaments once lengthened or broken can never, or only after a lapse ot 
many years, be completely restored, this deformity may be expected, in 
a certain number of cases, to continue, however exact and perfect may 
be the bony union. It must be added, however, that so long as the 
tilting of the fragment remains, the articular surface is actually present- 
ing somewhat to the radial side. While in the normal condition it 
presents downward, forward, and inward, it now presents, when the dis- 
placement is considerable, downward, backward, and outward. 

Diday maintained that there existed usually in this fracture an overlapping 
or shortening of the bone in its entire diameter, and Voillemier thought that the 
specimens which he had examined proved that an impaction was almost uni- 
versal, and Tillaux has observed it frequently. 

Both of these opinions Robert Smith has sought to combat, declaring that the 
appearance of impaction is due to the ensheathing callus, which is deposited 
usually, if the displacement is allowed to continue, in the retiring angle opposite 
the seat of fracture. Jajavay and Fouchat sustain the observations of Smith, 
but some recent observations made by Mr. Callender, of Saint Bartholomew's 
Hospital, London, go far to support the opinion that some impaction generally 
exists, but rather upon the posterior margin than upon either the radial or ulnar 
side; 1 and my own observations lead me to conclude that a posterior impaction 
is quite common. 

In a case reported by Dr. Cameron, of Glasgow, resulting in speedy death, the 
impaction was complete posteriorly, and was accompanied with impaction and 
comminution of the lower fragment, while the fracture in front was " hardly 
complete, the periosteum holding the fragments together." 2 

Comminution of the lower fragment has never occurred in the experi- 
ments made by me upon the cadaver, but it is quite common to meet 
with such examples in dead-house specimens, especially when the patients 
have fallen from a height and have been killed by the accident. Its 
existence usually implies the application of greater force than results 
from a fall upon the hand upon the sidewalk. The latter represents the 
usual accident, while a fall from a height is the exceptional accident, and 
the character of the fracture is therefore exceptional. 

i Callender, St. Barth. Hosp. Rep . p. 281, 1865. 
2 Cameron, Glas. Med. Journ., March, 1878. 



FRACTURES OF THE RADIUS. 



275 



[Mr. Powers, 1 of London, states that comminution is much more frequent than 
is supposed, as it is not easily detected. In 59 specimens he found comminution 
in 31. Callender, Hutchinson, and Bennett, also, have advanced the same 
view.] 

In the accompanying woodcut (Fig. 141) is seen an impacted and comminuted 
fracture of the lower end of the radius. Dr. James Wentworth, of Troy, IS". Y., 
who sent me the specimen, says that the patient, a man, set. fifty years, in a fit 
of delirium, jumped from a third-story window, alighting upon the stone pave- 
ment. He survived the accident less than one hour. 



Fig. 141. 



Fig. 142. 



Fig. 143. 






Impacted fracture. (Au- 
thor's collection.) 



Comminuted fracture, 
thor's collection.) 



(Au- 



Bigelow's case of com- 
minuted fracture of the 
lower end of the radius. 



Fig. 142 is from a specimen presented to me by Dr. William Van Buren, and 
was found in an autopsy at the New York City Hospital. In this specimen 
there is comminution without impaction or displacement. The line of separation 
between the upper and lower fragments is transverse, and the lower fragment is 
divided into five distinct pieces, each line of fracture involving the joint. 

One curious example of this form of fracture is reported by Dr. Bigelow, of 
Boston (Fig. 143). The patient had fallen, and, being otherwise seriously injured, 
ultimately died in the Massachusetts General Hospital. At first he had only 
complained of lameness at the wrist, as if it had been severely sprained ; but at 
the end of several days the joint became swollen, and from the persistence of the 
swelling Dr. Bigelow was led to diagnosticate a stellate crack in the articulating 
extremity of the radius, he having met with a similar case two years before, 
when a patient with the same symptoms had died of other injuries, and exhibited 
a crack in the same place, but less extensive than in this case. There was found, 
in this last example, a star-shaped fissure on the articulating surface, without 
displacement. These fissures penetrated the shaft for an inch or more. Dr. 
Bigelow thought that the bones of the wrist acted as a wedge to spread the cor- 
responding hollow of the articulating extremity, and that this specimen would 
explain the persistence of some cases of sprained wrist. 2 

Robert Smith has described a fracture occurring at the same point, and prob- 
ably possessing nearly the same characters as Colles's fracture, in which the lower 
fragment is thrown forward instead of backward, and which has generally been 
the result of a fall upon the back of the hand. There is no such specimen, how- 
ever, in any of the pathological collections in Dublin, nor has Mr. Smith ever 



1 Trans. Path. Soc. Lond., vol. xxxviii. 

2 Bigelow, Boston Med. and Surg. Journ., vol. lviii. p. 99. 



276 FKACTUEES OF THE RADIUS. 

seen a specimen obtained from the cadaver, although he reports a case which 
fell under his observation in practice. I have myself seen one such case, 1 but I 
regret to say that my examination of the condition of the arm was not such as 
to enable me to give a very satisfactory account of the cause and symptoms of 

the accident. Referring, however, to the 
F IG . 144. experiments upon the cadaver detailed in 

the succeeding pages, it will be seen that 

^_ ^ ~~ ~" \ x I have been able to produce this fracture 

p by forced palmar flexion of the hand. 





Fracture of the Styloid Processes 
Accompanying Colles's Fracture. — I 

believe I have seen two examples of a 

Fracture of radius and displacement „ . , r ,. . ., 

forward. (E. W. Smith.) fracture commencing on the radial side 

of the bone and terminating in the 
joint, the separated fragment including considerably more than the styloid 
process ; but neither of these cases has been verified by an autopsy. 

Nelaton observes that all the varieties of this fracture which he has seen are 
often accompanied with fracture of the styloid apophysis of the ulna, and with 
a tearing of the triangular ligament. Cameron, also, thinks it more common in 
connection with a Colles's fracture than has generally been supposed ; and, in 
confirmation of this opinion, reports five cases which he has himself observed. 2 

Dislocation of the Lower End of the Ulna in Connection with Colles's 
Fracture. — Dr. Moore, of Rochester, N. Y., has demonstrated, by exami- 
nations upon the cadaver and by experiment, that in a certain proportion 
of cases the internal lateral ligament, and the triangular fibro-cartilage 
give way under the force which has occasioned the fracture, the styloid 
process is thrust under or through the annular ligament and imprisoned ; 
in fact, the ulna becomes dislocated, and is retained by the annular liga- 
ment in its new position ; this dislocation being accompanied in some 
cases with a fracture of the styloid process of the ulna. Nor can the 
reduction of the fracture of the radius be accomplished until the ulna is 
released from its imprisonment. Reduction is to be accomplished by 
extension and partial circumduction ; the hand being grasped firmly and 
extended first to the radial side, then backward to the ulnar side, and 
finally forward, or in the position of flexion. During the entire manoeuvre 
the wrist is held firmly by the opposite hand of the surgeon. The test 
of reduction is to be found in the presence of the head of the ulna on the 
radial side of the ulnar extensor. In order to retain the ulna in place 
when reduction is effected, Dr. Moore places a thick, firm compress over 
its lower end, on the palmar and ulnar margins of the forearm, and secures 
this in place with a broad band of adhesive platter drawn firmly around 
the wrist. The forearm is then placed in a narrow sling passing under 
the wrist and compress. This completes the dressing. 3 

The five examples presented by Dr Moore, and verified by an autopsy, must 
be regarded as exceptional cases; all of them being results of falls from a consid- 
erable height, and most of them had proved speedily fatal, thus affording an 
opportunity for post-mortem inspection. They are not fair representatives of 

1 Trans. Amer. Med. Assoc, vol. ix. p. 145. 

2 H. C. Cameron, Glasgow Med. Journ , vol. x. No. 3,1878. 

3 Moore, New York Med. Eecord, April 1, 1870 ; March 20, 1880. 



FRACTURES OF THE RADIUS. 277 

that class of cases which are caused by falls upon the hand in the street, and 
which have been regarded as typical cases. Dr. Moore concludes, however, from 
autopsies, and from personal observation of other cases, that " luxation of the 
ulna exists in more than half of the cases. Bnt I was never able to produce it 
in any of my experiments upon the cadaver — that is to say, the extensor carpi 
ulnaris was never dislodged from its groove, and this is what he considers essen- 
tial to the luxation. By the change of position of the lower fragments of the 
radius and ulna the extensor carpi ulnaris is less distinctly felt, or it cannot be 
felt at all, but the dissection always shows that it remains in its groove. Indeed, 
I feel persuaded that it cannot be torn from its normal position except by great 
force, such as was applied in all the cases mentioned by Dr. Moore. 

[My experience in the treatment of Colles's fracture has led me to attach more 
importance to Dr. Moore's views than is expressed in the above text. The 
cases which he reports are by no means exceptional, and his explanation of the 
conditions which exist, and of the method of overcoming the peculiar form of 
displacement are deserving of careful study. Dr. Moore thus explains the acci- 
dent and the dislocation : 

"The fall comes upon the palm of the hand, and the radius which sustains 
the full forces of the strain gives way at a point near the wrist. The line of 
fracture is usually an oblique one, starting from a point on the anterior aspect 
of the radius, near the articulation, and running backward and upward, making 
the posterior surface of the lower fragment longer than the anterior. It is 
seldom more than an inch from the joint, and seldom so far. But the line of 
fracture is very various, sometimes simple and nearly transverse, but often com- 
minuted to the last degree. The luxation of the ulna exists in more than half 
of the cases. I now feel quite sure, though I cannot demonstrate it by dissec- 
tion, that a proper observation of the relation of the head of the ulna to the 
carpus will make a just diagnosis of its luxation or non-luxation. The force of 
the fall may be just balanced by the strength of the radius, but in the nature of 
such accidents this would not often be the case. In most, there would be some 
force still to be borne. Upon what structures does this fall? The radius 
instantly, on fracture, ceases to afford resistance, the hand is carried still further 
back, and then comes the strain on the attachments at the end of the ulna. It 
will be remembered that the ulna does not articulate with the wrist, but there 
is a distinct synovial cavity between its head and a strong membrane called the 
triangular fibro-cartilage. The membrane takes an origin from the rim and 
side of the radius, and, covering the head of the ulna, is inserted in the pit at 
theroot of the styloid process. As the hand, with its broken fragment of the 
radius, is forced backward, the strain is often sufficient to rupture the connection 
between the two bones or to break the ulna near the head. I have seen this 
double_ fracture twice only. The rupture takes place at the weakest point, 
which is its insertion in the pit at the root of the styloid process. But this is 
not the only resistance. The styloid is held to the carpus by the internal lateral 
ligament, which takes a very firm hold upon the end and radial surface of the 
styloid^ This also gives way, and usually does so in a peculiar manner — viz., 
by pulling off the surface of the bone, which proves to be weaker than the 
ligament. Thus the remaining styloid is brought to an edge like a gouge- 
chisel, and is shortened about one-half. When these resisting forces are dis- 
posed of, the end of the ulna, now laid bare, is pressed against the posterior 
annular ligament, and is apt to become engaged upon it either by a fold, or, 
what is more likely, by splitting its fibres and hooking upon it. If very great 
violence has been used in the production of these lesions, the head of the ulna 
will be driven forward through the annular ligament and skin, thus producing 
a compound luxation." 

Dr. Moore attaches much importance to the position of the tendon of the 
extensor carpi ulnaris in determining the question of the luxation of the lower 
extremity of the ulna. He says : " It runs alongside of the head of the ulna 
and behind the styloid. When the luxation does not exist, and the fracture 
does, the head of the bone maintains its relation with the tendon but little dis- 
turbed. When, however, the luxation does occur, the tendon will appear to lie 
over the head. I feel quite sure that this does not result from any twist of the 
hand carrying the fragment of the radius. I find proof of the correctness of this 



•11 



FRACTURES OF THE RADIUS. 



proposition in the specimen before us. The dead tissue presents the tendon 
curved out of its place. In the living, under muscular contraction, this would 
be a straight line, and lie over the head of the ulna. I find also in what I deem 
cases of luxation, a mobility of the end of the ulna incompatible with the integ- 
rity of the ligamentous apparatus. Every observer has recognized a difference 
of the form of the wrist in different cases. Some are curved backward — the 
genuine silver-fork shape ; others have the hand carried more laterally. My 
convictions are, that those that present the wrist well curved back, are more apt 
to be those of luxation of the ulna with fracture, but the lateral bend implies 
generally shortening of the radius from fracture without luxation of the ulna. 



Fig. 145. 



Fig. 146. 





Position of roller compr 



Roller, with adhesive strap applied. 



The methods of reduction and treatment are as follows : " I propose a form of 
traction and circumduction which is intended to disentangle the ulna and carry 
it up in its place between the tendons of the extensor carpi ulnaris and extensor 
minimi digiti. I by no means wish to say that it is always necessary, for the 
great point should be not to relax any effort until complete restoration has taken 
place. One of the best methods of reduction is to draw the hand of the patient 
around the knee of the surgeon, the head of the ulna resting upon his patella. 
The gentle handling that is ordinarily employed in the management of the frac- 
ture is out of place here. Great force is often necessary to restore the symmetry 
of the parts. We must keep in mind that a luxation is to be reduced, and 

Fig. 147. 




Colles' fracture ; dressing complete. 



should not cease our traction until the end is attained. Besides, the muscles 
will produce consecutive luxation instantly if the parts are not held firmly until 
the dressing is complete. With the thumb of the surgeon under the ulna, and 
the hand beneath, and the fingers upon the back of the wrist holding with great 
firmness, I apply my dressing. This, it will be remembered, consists of a simple 



FRACTURES OF THE RADIUS. 279 

roller from half to three-quarters of inch in diameter and two inches long. This 
is to be carefully placed under the ulna, abutting against the pisiform bone and 
slowly displacing the thumb. Then a strip of adhesive plaster of the same width 
is drawn, with as much force as it will bear, around the wrist and pinned to 
prevent relaxation. The band of plastered cloth is carefully adjusted so that 
the distal edge is brought around on a line with the end of the radius. It is 
manifest that this bandage will grasp the broken fragment, and hold it to the 
end of the ulna. The rule, of loose dressing at first, is distinctly violated for a 
purpose. I repeat that I draw it as firmly as I can, often breaking the plaster 
cloth. The dressing is entirely completed by the use of a sling which must not 
be more than three inches wide. This must be placed over the roller, and is 
made of this width to cause the whole bearing to come on the roller, which is 
both compress and splint. The hand is brought down and allowed to hang 
naturally. Thus its weight and that of the forearm are used to press the ulna 
upward into its proper place. " If all this is successfully accomplished, the 
broken fragments of the radius are easily kept in place. 

" The full length of the arm is maintained if the ulna does not fall down, and 
the tendons that run over the back of the wrist are so closely parallel to to make 
the best possible splint. I do not continue so gross a violation of the primary 
rule in dressing fractures, as to retain the bandage in its tight condition; but, 
after six hours, cut it by thrusting one blade of a pair of scissors under it on the 
back of the wrist, dividing it completely. The few hours of such retention seem 
to be sufficient. The meagreness of the appliance has startled some who have 
attempted its use. But any addition that I have made has injured it. I find 
there is a strong disposition on the part of the patient to lift up the hand with 
the sound one. With unintelligent patients this is often troublesome, and a 
splint of iron, thin, such as hoop iron, bent so as to come over the back of the 
wrist and hand, and bound upon the forearm but not upon the hand, will guard 
against this error. I am careful not to bind the hand to it, for I desire the con- 
stant action of gravity. The position can be maintained even in the recumbent 
posture. The slight motion in the joint which will necessarily be produced by 
allowing it to hang freely, prevents the stiffness that is so often a very serious 
incovenience after the treatment of this fracture."] 

In the following case, although the patient fell from a considerable height, 
and the lower fragment of the broken radius was comminuted, there was no dis- 
placement of the ulna. J. B., set. 62, fell twenty-four feet, and was taken to St. 
Mary's Hospital, Detroit. He was found to have a rupture of the left gluteal 
artery, and a fracture of the right radius. Dr. McGraw tied the gluteal artery 
by an external incision, but death occurred on the same day. The autopsy dis- 
closed a Colles's fracture. The ulna was found in its place. No ligaments any- 
where around the joint were broken or injured in the least, neither was there 
any extravasation of blood near the fracture. The lower end of the radius was 
broken into four fragments, which were, however, held together by the perios- 
teum and ligaments. They were broken off the shaft just one-half inch from the 
articular surface, and were inclined back with the characteristic deformity. It 
was with difficulty that they could be brought into proper apposition, and only 
by first making traction, and then bending toward the palmar surface. It was 
evident that they were held in their acquired position by bony impaction and 
by nothing else. It was difficult even when the bones were bare of flesh to get 
much crepitus, owing to the'spongy consistency of the bone at that point. 1 

Barton's Fracture, as distinguished from a Colles's Fracture. — Dr. 

J. Rhea Barton, 2 of Philadelphia, described a form of fracture occurring 
through the lower end of the radius, which is probably much less common 
than Colles's fracture, and which had hitherto escaped the notice of sur- 
geons. Its peculiarity consists in the line of fracture extending very 
obliquely from the articulation, upward and backward, separating and 
displacing the whole or only a portion, as the case may be, of the pos- 

1 McGraw, Med. Gaz., Jan. 8, 1881. 2 Philada. Med. Exam., 1838. 



280 FRACTURES OF THE RADIUS. 

terior margin of the articulating surfaee. I have not recognized this 
fracture in any instance which has come under my own observation, nor 
have I been able to find a cabinet specimen in any pathological collection. 

Dr. Barton was not able to prove the correctness of his diagnosis by an 
autopsy, and the only well-authenticated example which I can find upon record 
is that to which Malgaigne has alluded, as having been seen by M. Lenoir, and 
of which an account was published in the Archives Generates de Medecine, in 1839. 
M. Lenoir believed it to be a simple luxation of the hand backward, but the 
patient having died, he was able to correct his diagnosis by an autopsy. A 
considerable fragment had been broken from the posterior lip of the articular 
surface, the line of fracture being from below upward, and from before back- 
ward. This fragment had become displaced upward and backward, carrying 
with it the carpal bones, and producing thus the appearance of a simple dis- 
location. 1 

The possibility of such a fracture must be admitted, since in my expe- 
riments upon the cadaver by avulsion, it has several times been produced ; 
but the infrequency of cabinet specimens furnishes a presumption that it 
is exceedingly rare and exceptional. 

Etiology and Mechanism of Colles's Fracture. — In every instance, 
except one, which has come under my notice, where the cause of a Colles's 
fracture has been ascertained, it has been occasioned by a fall upon the 
palm of the hand. 

The exceptional case was in the person of Mrs. D. B., who fell in getting out 
of a street-car in the city of New York, May 20, 1865, striking upon the back 
of her hand while the hand was shut. The displacement was in the same direc- 
tion as in cases caused by a fall upon the palm. Robert Smith has seen a 
similar accident cause a displacement of the fragment forward. 

As to the precise mechanism of this accident — speaking now only of 
the well-characterized Colles's fracture — there can be very little doubt. 
In a large majority of examples it is the result, primarily and mainly, of 
two forces acting in an opposite direction, at an obtuse angle, one being 
the weight of the body in falling, and the other the impact or resistance 
of the ground, the bone giving way, as is usual in other long bones, 
nearest the point of impact, where, owing to the unyielding nature of the 
resistance as compared with the yielding nature of the impulse (or weight 
of the body), the vibration is the greatest ; and in this particular case, the 
fracture is not only almost always in the lower end of the bone, but also 
at or near that point where the bone is less strong than elsewhere, 
namely, where the compact tissue ends and the more spongy tissue 
commences. 

This view of its mechanism was illustrated experimentally by M. Nelaton. 2 
Having amputated the forearm upon a cadaver, and sawn off the olecranon pro- 
cess, he placed the palm of the hand upon a solid surface, the forearm being 
vertical, and then struck a heavy blow upon the upper end of the two bones. 
Upon dissection he found the radius broken transversely, twelve to fifteen milli- 
metres from the lower end, the lower fragment being tilted backward. 

1 Malgaigne, Traite des Frac, etc., torn. ii. p. 700. 
2 Nelaton,Chir. Path., t. i. p. 740. 



FRACTURES OF THE RADIUS. 



281 



I have repeated this experiment, and with the same result. It is not easy, 
however, to produce the fracture in this way upon the cadaver, unless we select 
the bones of young persons or delicate women for the experiment ; the force 



Fig. 148. 



Fig. 149. 





Transverse fracture of the lower end of 
radius; caused by forced palmar flexion; 
in the cadaver. 



Transverse fracture of lower end of radius : 
caused by forced dorsal flexion; in the 
cadaver. A. Internal lateral ligament. 
B. Third fasciculus of anterior carpal liga- 
ment. C. Anterior radio-ulnar ligament. 



required to cause the fracture being greater than is required in the living 
subject, because the muscles are relaxed and the stability of the bones is not 
well maintained. 

We see, then, that in addition to the two forces acting in opposite 
directions, already mentioned as constituting, in most cases, the efficient 
cause of the fracture, there must be added, as extrinsic, but important, 
muscular action, which insures the fixedness of the articulation at the 
elbow and wrist. 

In a few cases also the mechanism of the fracture will admit of another 
explanation. A Colles's fracture has been caused in the living subject 
by simply forcing the hand strongly backward, and without a fall or 
sudden impact. 

Thus Voillemier, 1842, relates that he had seen the fracture once caused by a 
fall upon the lower half of the hand, in which the heel of the hand did not 
touch the ground ; but another case was even more conclusive, the fracture being 
caused by forced flexion (probably ''dorsal flexion") made by a comrade. 
According to Malgaigne, M. Bouchet was the first to observe this mode of 
causing the fracture ; his observations having been made exclusively upon the 
cadaver (1834). In trying to dislocate the wrist, he found he could produce only 



282 FKACTURES OF THE RADIUS. 

a fracture of the lower end of the radius, sometimes with other lesions, and 
especially with fracture of the styloid process. 1 

Malgaigne, while accepting the theory of Bouchet — that is, while regarding 
the fracture as being produced by the action of two opposite forces — the weight 
of the body, and the resistance of the soil — declared that the observations of 
Bouchet and Voillemier led him to believe that cases of fracture by arrachement 
(a cross-strain of the ligaments) might be more common than had been supposed. 

In 1860-61, an important memoir by M. Ozanim Lecomte 2 appeared, in which 
that surgeon stated that it was his opinion that the fracture was produced solely 
by arrachement, and that neither muscular action nor shock had any part in it. 
This opinion was supported by Duplay, Anger, 3 and Tillaux, 4 the latter of whom 
says: k 'I agree with Lecomte in admitting that the classical fracture of the 
lower end of the radius is always produced by an avulsion caused by the liga- 
ments." 

According to Dr. P. S. Conner, 5 of Cincinnati, Dr. Gordon, of Belfast, in a 
memoir on Colles's fracture, published in 1875, maintained that the bony lesion 
is " due to a transverse rupture of the fibres of the lower end of the radius, as a 
result of forced extension of the hand." Dr. Conner, who made experiments 
regarding the subject, says that they have demonstrated to him the correctness 
of that theory. 

In May, 1878, Dr. Lewis A. Pilcher, of Brooklyn, N. Y., 6 repeating the experi- 
ments of his predecessors, came to an identical conclusion, viz., that Colles's 
fracture is due to an arrachement, caused by the dorsal flexion of the wrist. A 
few of Dr. Pilcher's observations deserve to be mentioned, on account of their 
importance. For example, he has noticed that if the dorsal flexion of the wrist 
is carried to extremes, and if the interior fragment is very much tilted back- 
ward, the periosteum on the posterior surface of the bone, which is reinforced 
by a certain number of aponeurotic fibres, is torn or detached from the radius, 
thus allowing the inferior fragment to ascend backward, and to be penetrated 
by the posterior border of the superior fragment. 

Dr. Pilcher has also observed that the chief cause of the peculiar position 
assumed by the hand after this fracture was the presence of " a strong oblique 
fasciculus of the anterior ligament of the wrist, which extended from the cunei- 
form bone to the anterior border of the styloid process of the ulna. By the 
backward displacement of the carpus, and the attached radial fragment, that 
ligament was put upon the stretch, limiting all motion until relaxed." 

It will be seen that Dr. Pilcher attributes nothing of the peculiar phenomena 
to the integrity of the internal lateral, triangular, and radio-ulnar ligaments ; 
but to my mind it is very plain that this view of the subject is too exclusive, 
and that whenever these latter ligaments remain untorn they contribute to the 
malposition of the hand. 

I have repeated these experiments of Bouchet, Lecomte, and others, many 
times upon the cadaver; and while they confirm in some measure the observa-. 
tions of these surgeons, I am far from being convinced that the classical frac- 
ture, occasioned by a fall upon the palm of the hand, is due exclusively to 
the action of the ligaments. I presented to the Surgical Society of New York, 
twelve specimens of Colles's fracture, and compared them with a still larger 
number of specimens in which the fracture had been produced upon the cadaver 
by forced dorsal flexion. The comparison showed that there was a marked 
difference between the two classes of fractures, as regards the seat and direction 
of the lesion. 7 

The results of my experiments upon the cadaver may be summarized 
as follows : 1st. In some there is only a laceration of the anterior annular 

1 Bouchet, These sur les lux. du poignet. Paris, July, 1834. From Malgaigne. 

2 Lecomte, Archiv Gen. de Med., Dec. 1860, Jan. and Feb. 1861. 

3 Anger, Frac. et Lux. Atlas, Paris, 1863. 

4 Tillaux, Trait. d'Anat. Topograph., Paris, 1877, p. 605. 

5 Conner, Cincinnati Lancet, April 23, 1881. 

6 Pilcher, paper read before the Surgical Section of the New York Acad, of Med., May 
16, 1878; The Med. Record, July 27, 1878, p. 74. 

' Med. Record, July 25 and 30, 1881. 



FEACTURES OF THE RADIUS. 



283 



Fig. 150. 



ligament of the wrist, which, occurring in the living subject, would pass 
for a sprain of the wrist. 2d. The styloid process of the radius may be 
alone broken off at its base. 3d. The an- 
terior lip of the radius may be broken off, 
the line of fracture being transverse, but 
not involving the whole thickness of the 
bone. 4th. The line of fracture is occa- 
sionally oblique from the ulnar to the 
radial side of the radius, commencing out- 
side of the joint and terminating in the 
joint. 5th. The line of fracture is some- 
times transverse, involving the entire thick- 
ness of the bone: but it is usually much 
lower down than when it is caused, in the 
living subject, by a fall upon the hand; 
and there is less obliquity in the line of 
fracture from before back, than in the 
latter case. 6th. That portion of the carpal 
ligament which passes obliquely downward 
to be inserted into the styloid process of 
the ulna is always untorn, while rupture 
of the radio-ulnar, triangular, and internal 
lateral ligament is occasionally found. 7th. 
In some cases there is a mere fissure or 
crack of the bone, not extending through 
its entire thickness, and which could not 
have been recognized in the living subject. 
8th. In others it is more or less tilted or pressed back, but not over- 
lapped ; and these, constituting a majority of the whole, were easily 
replaced in their natural position by simply pressing the lower frag- 
ment forward, as has been my practice in many cases hitherto. 9th. 
When the force applied is greater or longer continued the lower frag- 
ment is displaced backward upon the upper, the periosteum is torn 
up posteriorly ; and there would be impaction, no doubt, if the mus- 
cles had their normal power of contraction, or if added to the cross- 
strain there had been the driving force of a fall upon the palm of the 
hand ; and in these cases it was difficult to tilt the lower fragment 
forward into line without first relieving the strain upon this periosteal 
ligament by the method described by Pilcher. 10th. The character 
of the lesions in the opposite wrist of the same cadaver was generally 
symmetrical ; the same lesion being caused by the same manipulation 
in one arm as in the other. 11th. Fractures of the radius were produced 
by forced palmar flexion, but not quite so readily, and the fractures 
occurred a little lower than is usual in a Colles's fracture. 




Fracture at base of styloid process 
of radius, and laceration of annular 
ligament, caused by forced dorsal 
flexion ; in the cadaver. 



These are the facts as observed by me in the dead-house experiments, and no 
doubt they illustrate to some extent the mechanism of this accident as it occurs 
in life ; but it is apparent that in some respects the circumstances differ. There 
is in the case of the cadaver no muscular contraction to give fixedness to the 
bones, and to displace the fragments after they are separated, or to maintain 
them in a position of displacement. The force of sudden impact caused by the 



284 FRACTURES OF THE RADIUS. 

weight of the body in falling is not present. In short, the fractures caused by 
the experiments were the result solely of the action of the carpal ligaments 
upon the lower ends of the bones ; they were fractures by avulsion or cross- 
strain, while in the examples presented in the living subject they are usually the 
result of concussion, avulsion, and muscular action combined, of which causes 
perhaps the cross-strain is not the least efficient. 

Prognosis. — One hundred and five examples of Colles's fracture have 
furnished no cases of non-union, nor indeed do I remember ever to have 
seen the union delayed ; but in a pretty large proportion of cases occur- 
ring in the practice of surgeons whose patients have been brought under 
my notice, some slight or considerable deformity remains, and in most 
cases the joint remains more or less stiff and sensitive for some months. 

Twice I have found the wrist and finger-joints quite stiff after a lapse of one 
year; in one case I have found the same conditions after two years, in one case 
after three years, and in two cases after five years. 

In cases treated by myself, where I have exercised great care in 
reducing the fragments thoroughly, and where the bandages and splints 
have not been applied too tightly, nor kept on too long, deformity to any 
considerable extent is the exception, and the stiffness is soon dissipated. 
I say it has been the exception, not intending to claim that under my 
care considerable deformity has never resulted. 

Confining our remarks still to Colles's fracture, the deformity which 
has been observed most often, after the lapse of several months or years, 
is a projection of the lower end of the ulna inward, a phenomenon ex- 
plained fully in the preceding pages. Rarely it is displaced backward, 
and still more rarely forward. In a majority of cases this is accompa- 
nied with a perceptible falling of the hand to the radial side, while in a 
few it is not. After this, in point of frequency, I have met with the 
backward inclination of the lower fragment. 



o 



Eobert Smith found this displacement almost constant in the cabinet specimen 
examined by him ; and it is very probable that nearly all of the specimens 
examined by myself would present more or less of the same deviations upon the 
naked bone; but in the living examples a slight deviation would be concealed 
by the numerous tendons which cover this part of the arm, and perhaps by some 
permanent effusions, of which I shall speak more particularly presently. 

There remains for a long time, in many cases, a broad, firm, uniform 
swelling on the palmar surface of the forearm, commencing near the upper 
margin of the annular ligament and extending upward two inches or 
more. The swelling continues much longer in old and feeble persons 
than in the young and vigorous. It is pretty generally proportioned to 
the amount of ankylosis existing at the wrist and finger-joints, and it 
disappears usually pari passu with these conditions. There can be no 
doubt that this phenomenon is due to effusions along the sheaths of the 
tendons, and in the areolar tissue external to the sheaths, and it is as 
often present after sprains and other severe injuries about this part, as 
in fractures. In many cases, however, its prolonged continuance and its 
firmness have led to a suspicion that the bones were displaced, a sus- 
picion which only a moderate degree of care in the examination ought 



FRACTURES OF THE RADIUS. 285 

easily to dispel. A similar effusion, but in less amount, is frequently 
seen also on the back of the hand, below the annular ligament. When 
both exist simultaneously the appearances of deformity and of displace- 
ment are greatly increased. Here, then, Ave shall find a partial expla- 
nation of the ankylosis in the wrist and finger-joints, which continues 
occasionally many months, or even years, if, indeed, it is not permanent: 
an ankylosis produced in a few instances by extension of the inflamma- 
tion to these joints, but much more often by the inflammatory effusion 
and consequent adhesions along the thecae and serous sheaths, through 
which the tendons all pass in their course to the hands and fingers, and 
also by simple contraction of the articular ligaments, as a consequence 
of disuse, or, as it is usually termed, by passive contraction of these liga- 
ments. The fingers are quite as often thus ankylosed after this fracture 
as the wrist-joint itself; a circumstance which is wholly inexplicable on 
the doctrine that the ankylosis is due to an inflammation in the joints. 
Indeed, I have seen the fingers rig-id after many months, when, having- 
observed the case throughout myself, I was certain that no inflammatory 
action had ever reached them. 

The peculiar swellings of the wrist and hand which have been described 
above, commence to show themselves very early after the receipt of the 
injury ; but I have noticed, also, a swelling which is a little later in its 
accession, namely, an induration and fulness upon the back of the hand^ 
which corresponds accurately to the position of the carpal bones, and 
presents an appearance as if all the carpal bones were slightly displaced 
backward. This phenomenon is probably due to a swelling and indura- 
tion of the numerous ligaments which bind together these bones poste- 
riorly. It usually disappears after a few months. Nor is it any more 
difficult to show, I think, that the ankylosis of the wrist-joint is not often 
due to a malposition of its articular surfaces, as has frequently been 
asserted in the written treatises. 

The most superficial examination of the mechanism of this joint ought 
to satisfy us that any moderate or even considerable malposition of the 
loAver fragment after a fracture of the radius, is not sufficient in itself 
to occasion ankylosis. It is true that in the fracture now under con- 
sideration, the direction of the articular surface of the radius is often 
changed, and that, while it was directed downward, forward, and to the- 
ulnar side, it is now, perhaps, directed downward, backward, and to the 
radial side. But of what consequence is this so long as the carpal bones, 
with which alone this bone is articulated, preserve their relations to the 
radius unchanged ? 

If any other evidence be demanded, it may be supplied by the expe- 
rience of most surgeons in examples of ankylosis without displacement, 
in examples of displacement Avithout ankylosis, but in which the anky- 
losis has yielded gradually to the lapse of time, while the displacement 
has continued. 

The following case is in point : J. E., a private in the loth N. Y. Volunteers, 
fell from a height into a ditch during the battle of Fair Oaks, Va., May 31, 1862, 
striking upon the palm of his left hand, and causing a simple fracture near the 
lower end of the radius, accompanied probably with impaction. I do not knoAv 
what treatment was adopted, but when he came under my observation, in March, 



286 FRACTURES OF THE RADIUS. 

1863, at the Central Park General Hospital, New York, I found the most extra- 
ordinary deflection of the hand to the radial side which I have ever seen after 
this fracture, The hand could be turned laterally in the direction of the radius, 
to a right angle with the arm ; the motions of flexion and extension were nearly 
as perfect as in the opposite arm, and the hand was in all respects as useful as 
before the accident. 

To what I have said as to the prognosis in these accidents, I may be permitted 
to add the opinion of our distinguished countryman Dr. Mott, given in a clinical 
lecture before his class in the University Medical College of New York : 
u Fractures of the radius within two inches of the wrist, where treated by the 
most eminent surgeons, are of very difficult management so as to avoid all 
deformity; indeed, more or less deformity may occur under the treatment of the 
most eminent surgeons, and more or less imperfection in the morion of the wrist 
or radius is very apt to follow for a longer or a shorter time. Even when the 
fracture is well cured, an anterior prominence at the wrist, or near it, will some- 
times result from swelling of the soft parts.'' The reporter, a surgeon, adds : "As 
the above opinion of Professor Mott coincides with my own observations, both 
in Europe and in this city, as well as with many of our most distinguished sur- 
gical authorities, I venture to hope that it may assist in removing some of the 
groundless and ill-merited aspersions which are occasionally thrown on the 
members of our profession by the ignorant or designing." 1 

In evidence that we have not yet attained all that we could desire in the 
treatment of this fracture, I will quote farther: " In young subjects, fractures of 
the lower end of the radius are easily reduced, unite readily, and leave the use 
of the limb perfectly unimpaired ; but in old persons, who, as before stated, are 
especially liable to this injury, the result is often most unsatisfactory, even after 
the greatest care has been used during the treatment. It is frequently months 
before the hand is free from pain and regains its proper motions, and too often 
an unsightly, crooked, and permanently stiff wrist remains, to the great incon- 
venience and annoyan.ce of the patient." 2 

Treatment. — The peculiar character of the displacement which char- 
acterizes Colles's fracture, and the constant difficulty experienced by 
surgeons in obviating deformity, have led to much speculation and in- 
genious invention ; and modern surgeons, especially, have thought it 
necessary to introduce here an essential modification of the usual apparel 
for broken forearms. This modification consists in employing a pistol- 
shaped splint, instead of a straight splint, by means of which the hand 
may be thrown more or less strongly to the ulnar side. 

Heister s speaks of inclining the hand toward the ulna, while reducing a frac- 
ture of the radius, but when the reduction has been effected he recommends a 
straight splint. Among the first to advocate the permanent confinement of the 
hand in this position, were Mr. Cline, 4 and Dupuytren. 3 Mr. Cline, and after 
him Bransby Cooper, 6 and Mr. South, 7 recommend the ordinary straight splints 
for the forearm, bnt the rollers by which the splints are secured in place are not 
permitted to extend lower than the wrist ; so that when the forearm is suspended 
in a sling, in a state of semi-pronation, the hand shall fall by its own weight to 
the ulnar side. 

Dupuytren, and after him Chelius, adopt, in addition to the palmar and dorsal 
splints, the "attelle cubitale," or ulnar splint; which is a gutter, composed of 
steel, iron, tin, or some other metal, and made to fit the ulnar margin of the 

1 Boston Med. and Surg. Journal, vol. xxv. p. 289. 

2 Holmes's System of Surgery, Amer. ed., 1870, vol. ii. p. 798. 

3 De Lavrentii Heisteri, Institutiones CnirurgicEe, pars prima, p. 203, Amsterdam ed., 
1739. 

4 Malgaigne, Traite de Frac, etc., torn. i. p. 614, Paris ed. 

5 Dupuytren on Bones, London ed., p. 140. 

6 B. Cooper, Lectures on Surg., p. 232, American ed. 

7 Chelius's Surg., vol. i. p. 613. 



FRACTURES OF THE RADIUS. 



287 



forearm and hand, when the hand is drawn forcibly to the ulnar side. Blandin, 1 
Nelaton, 2 and G-ourand, 3 also, under certain contingencies employ the same. 
Most surgeons, however, employ either a palmar or a dorsal splint; or both 



Fig. 151. 




ISTelaton's splint for fracture of the radius. 



palmar and dorsal splints constructed with a knee, or pistol-shaped, and they 
thus avoid the necessity of the ulnar splint. Thus, Nelaton, 4 Robert Smith, 5 
and Erichsen, 6 recommend this peculiar form only in the dorsal splint ; while 

Fig. 152. 




Bond's splint. 



Fig. 153. 




Hay's splint. 

Bond, 7 Hays, 8 E. P. Smith, 9 G. F. Shrady, 10 and others, especially among the 
Americans, place the pistol-shaped splint against the palmar surface of the arm. 
A few modern surgeons have not seen fit to adopt this peculiar principle of 



1 Malgaigne, op. cit., torn. i. p. 614. 

2 Nelaton, Elem. de Path. Chir., torn. i. p. 747. 

8 Ibid., p. 746. 

5 R. Smith, op. cit., p. 168. 

7 Bond. Amer. Journ. Med. Sci., April, 1852. 

9 E. P. Smith, Buffalo Med. Journ., vol. ix. p. 225. 

10 Shrady, Amer. Med. Times, 2 cases, Dec. 22, 1860. 



4 N"elaton, op. cit., p. 747. 
6 Erichsen, Surgery, p. 215. 
8 Ibid., Jan. 1853. 



288 



FRACTURES OF THE RADIUS, 



treatment, or this form of dressing under any of its modifications. Colles 1 recom- 
mends a straight palmar and dorsal splint, and does not incline the hand. Barton 2 
advises the same, and Skey, having declared his preference for a couple of broad, 
straight splints, adds : " Great care should be taken to prevent the hand falling, 
and this object will be attained by inclosing the entire forearm and hand in a 
well-applied sling." 3 

Fig. 154. 




E. P. Smith's splint. 



Surface applied to forearm. A. Forearm piece, made of felt, 
with incurvated margins. 



Fig. 155. 




E. P. Smith's splint. B. Opposite surface. B, the hand-block, is connected with the 
forearm piece by two circular brass plates, which move upon each other, in order that the 
hand-block may assume any desired angle with the arm. In this way it may be adapted 
to either the right or left arm. It is fixed by a nut, seen on the brass plate. The letters 
C C indicate the extent of motion allowed to tbe hand-block. 



Stephen Smith employs two broad, straight palmar and dorsal splints, secured 
in position by adhesive strips, the hand being thrown to the ulnar side by 
reversed turns of adhesive plaster. 

[The dressing referred to is as follows : Take two thin but firm pieces of board, 
each a little wider than the entire arm ; make both of the splints slightly pistol- 
shaped at the lower extremity extending from two inches below the centre of the 



Fig. 156. 




Position of strips on the splints. 



Fig. 157. 




Dressing complete. 



elbow when flexed, to the'middle of the metacarpal bones of the hand (the splint 
for the posterior surface may be straight, and extend only to the carpo-meta- 
carpal articulation) ; place a layer of cotton wadding along the surface of the 



1 Colles, Lectures on Surgery, p. 325. 
3 Skey, Operative Surgery, p. 1 61. 



Barton, Phil. Med. Exam., 1838. 



FRACTURES OF THE RADIUS. 289 

splint next to the limb, thickest in the centre line, and add some cotton in mass 
so as to make compresses for additional pressure on the palmar and dorsal promi- 
nences of the misplaced bones, and cover each splint with a firm bandage ; next 
cut two strips of common adhesive or rubber plaster, each two inches wide, and 
twenty-four inches in length. Apply one end of each to the outer side of the 
palmar splint, but overlapping the inner side, the adhesive surface next to the 
splint, the upper strip being near the upper end, and the lower at a point which 
will bring its lower margin under the styloid process of the ulna. Place this 
splint on the palmar surface of the forearm, and bring the adhesive strips over 
the outer side ; now place the posterior splint in position, and bring the adhe- 
sive strips down over its outside, and around under the arm, then over the two 
splints, and thus complete the dressing. When properly applied this dressing 
has the following advantages : 1. The limb is uncovered ; 2. It is supported in 
a sling between the splints; 3. Pressure is made accurately on the dorsal and 
palmar deformities ; 4. Pressure is made on the styloid process of the ulna ; 5. 
The hand is maintained in a position between pronation and supination ; 6. If 
the dressing proves too tight, anyone may loosen it by raising the ends of the 
plaster sufficiently, and then reapplying them ; the fingers and wrist have very 
free motion.] 

Professor Fauger, of Copenhagen, has undertaken to treat this fracture in 
some sense without any splint, the forearm and hand being simply laid over a 
double-inclined plane, so as to bring the wrist into a state of forced flexion. 
" The hand having been brought into a position of strong flexion, the forearm is 
placed, pronated, on an oblique plane, with the carpus highest, the hand being 
permitted to hang freely down the perpendicular end of the plane." 1 M. Vel- 
peau, in a report of his surgical clinic at La Charite for the year ending Sep- 
tember, 1846, says this plan has been tried during this year, and "the result has 
not been very satisfactory. The experiment, however, has not been decisive 
upon this mode of treatment." 2 

Fig. 158. 




Hewit's splint. 

The late Henry S. Hewit, of this city, devised a very ingenious splint, by 
which the mobility of the wrist and fingers might be more perfectly retained, 
and the wrist put into any desirable position. The following is the description 
given by himself of the apparatus : " The wooden ball grasped by the hand is 
connected by a rod to a slender bar running longitudinally upon the face of the 
splint, and capable of being flexed at any desirable length. The rod is attached 
to the travelling connection by a universal joint, giving play to the ball in lim- 
ited movements of flexion, extension, pronation, and supination. The natural 
tendency is for the patient to make these movements, and perpetually to relax 
and contract the fingers. The splint upon the inner surface of the arm is antag- 
onized by a plain flat splint on the outer surface, extending to the superior 
border of the wrist-joint. This splint has been used for upward of two years 
by myself and others, and has given good results." 3 

1 Fauger, London Lancet, May 8, 1857. 

2 Velpean, Boston Med. Journ., vol. xxxv. p. 213. 

3 Hewit, Med. Record, April 1, 1873. 

19 



290 FRACTURES OF THE RADIUS. 

[Dr. White, of Toronto, Canada, has used a cuff splint, not unlike Hewit's in 
its application to the wrist, with alleged success. 1 ] 

We come now to consider how far this peculiar treatment, ulnar incli- 
nation, is capable of answering the special indication of the case we are 
studying. It is assumed, as I have already intimated, that by bearing 
the hand strongly to the ulnar side, the fragments of the radius are brought 
more exactly into apposition, and more easily and effectually retained ; 
an assumption which supposes two things to have been determined : first, 
that there exists an overlapping of the fragments, either through the 
whole extent of their broken surfaces, or especially toward the radial side, 
or that the upper end of the lower fragment is inclined to fall against 
the ulna, or that all of these several conditions coexist ; and, secondly, 
that if such displacements do exist, they can be remedied by this manoeuvre. 
The first of these suppositions seems to have been sufficiently considered 
by all those gentlemen who have particularly examined the specimens 
contained in the various pathological collections, and to whose careful 
investigations I have already frequently adverted. With rare excep- 
tions, none of these displacements have been found to exist, although, as 
has been observed, a casual inspection of the arm when recently broken 
would often lead to an opposite conclusion. I do not here speak of im- 
paction which is usually upon the posterior margin, if it exists at all. 

In regard to the second supposition, namely, that, where such dis- 
placements do exist, a forced adduction will aid in the retention of the 
fragments, I shall have to speak more cautiously, because, so far as I 
know, my opinions have received as yet no public and authoritative 
indorsement. In order that adduction may prove effective, there must 
be some point upon which to act as a fulcrum. It is of no use that we 
rotate the hand for the purpose of making extension unless there can be 
found a resistance or fulcrum upon which the rotary motion may be per- 
formed. Such a fulcrum exists, no doubt, but to determine its availa- 
bility we must ascertain its character and position. It is not in the lower 
end of the ulna, for the ulna has no point of contact with the carpal 
bones, and when, in the natural state of these parts, the hand is inclined 
to the ulnar side, the lower end of the ulna rides freely downward upon 
the wrist until arrested by the ligaments which unite it with the carpus, 
or by the capacity of the joint to admit of motion in this direction. 
When the lower end of the radius is broken, and the ligaments of the 
joint are more or less torn, the ulna, although thrust downward much 
farther, perhaps, than it could ever descend in its normal state, still fails 
to find a support, and spreading wider and wider from the radius as it is 
thrust further upon the hand, no limit can be given to its progress in this 
direction. It was thus that, in one example already mentioned, I found 
the ulna carried downward one inch or more, and this was the fact in 
several cases reported by Moore, and verified by the autopsy. 

The resistance will, then, in nearly all cases, be found to be in those 
ligaments which bind the lower fragment to the lower end of the ulna, 
and the ulna to the carpal bones, viz., the radio-ulnar, the triangular, 
and the internal lateral ligaments, which in the normal state of the parts 

1 Canada Practitioner, May, 1889. 



FKACTURES OF THE RADIUS. 291 

constitute the centre upon which forced adduction expends its power, and 
which still continue to be the point of resistance when the radius is 
broken. But how feeble and uncertain must be a resistance which 
depends solely on these injured and often lacerated ligaments ! And 
how painful to the patient must be an extension sufficient to overcome 
the action of nearly all the muscles of the wrist, which is borne entirely 
by a few torn and inflamed fibres 1 Even in health this position, when 
forced, cannot be endured beyond a few seconds, and it must be difficult 
to estimate the sufferings which the same position must occasion when 
the ligaments are torn and inflamed. 

I am not to be told that surgeons have not intended to advocate this 
extreme practice; that they have never recommended forced adduction, 
but only a moderate and easy lateral inclination, such as can be com- 
fortably borne. If they have not, then they should not have spoken of 
making extension by this means. An easy lateral inclination has no 
more power to do good, so far as extension is concerned, than it has power 
to do harm. But the fact is, while a majority of surgeons have no doubt 
used less force than was hurtful, some have used more than was useful or 
safe ; indeed, the sharpness of the curve given to the splints figured and 
recommended by Dupuytren, Nelaton, and others, sufficiently indicates 
that their distinguished inventors intended to accomplish by these means 
a forced and violent adduction. 

Malgaigne, speaking of other means of extension applied to the forearm, sug- 
gested by Godin, Diday, and Velpeau, intended to operate only in a straight 
line, and alluding especially to the modes devised by Huguier and Velpeau, 
remarks : "Without discussing here the comparative value of the two forms of 
apparatus, I believe that they could scarcely be endured by the patients ; and M. 
Diday tells us that, in the trials which he has made, the pain produced by the 
extension was so great that he was compelled to renounce it." Which observa- 
tions cannot but apply equally to this plan of extension by adduction or to any 
other which might be adopted. Dr. G. S. Porter, of Lonaconing, Maryland, has 
used for the purpose of extension a padded wire-splint applied to the dorsal sur- 
face of the arm and hand, and in which the extension is supposed to be effected 
by adhesive plaster strips. 1 Notwithstanding the testimony which the experi- 
ence of this gentlemen has furnished of the value of this method, and not doubt- 
ing that he obtained satisfactory results, I must be permitted to say that proba- 
ably they were due to the thoroughness with which he reduced the fracture in 
the first place, rather than to the efficiency of the apparatus ; and I will take this 
opportunity of saying that the success claimed by Drs. Moore and Pilcher for 
their peculiar modes of treatment, neither of whom employs splints, depends, in 
my opinion, wholly upon the fact that they have had the good judgment and 
skill to reduce the fragments effectually in the first instance, after which, as I 
have already said, there is usually very little probability that they will become 
displaced. In cases which have been treated under my observation, these 
methods have given no better results than have other methods ; indeed, I have 
not thought the success equal to that obtained by my own, and some other modes 
of dressing, for which, however, much less has been claimed. 

It must not be inferred that I have concluded to reject this mode of 
dressing — the pistol-shaped splint — in all of its modifications ; for 
although I am far from being persuaded of its utility as a means of 
extension and retention in any case, yet I am not prepared to deny to it 

1 Porter, Med. and Surg. Reporter. April 14, 1877. 



292 FEACTURES OF THE RADIUS. 

some very considerable value in another point of view ; and when judi- 
ciously employed it can certainly do no harm. It is, I repeat, for another 
reason altogether than the one heretofore assigned, that I would recom- 
mend its continuance, a reason which I cannot so well explain, or hope 
to render intelligible, except to the practical surgeon. This position 
throws the whole lower end of both radius and ulna outward toward the 
radial margin of the splints, and by keeping the radius more completely 
in view, it enables the surgeon better to judge of the accuracy of the 
reduction, and to recognize more readily the condition and situation of 
the compresses, etc. This alone I have always considered a sufficient 
ground for retaining the angular splint ; although I have treated a great 
number of arms satisfactorily with the straight splints alone. 

Finally, while surgeons have been seeking to meet an indication, the 
existence of which is at least rendered doubtful, and by means which 
appear to me totally inadequate if it did exist, they have probably too 
often overlooked or regarded indifferently an indication which is almost 
uniformly present, namely, to press thoroughly forward the tilted frag- 
ment by a force applied upon the wrist from behind, and to retain it in 
place by suitable compresses. And I cannot help thinking, that, if they 
had regarded this as the sole indication in most cases, an indication 
generally so easily met, they would have made fewer crooked arms, and 
have saved their patients much suffering and themselves much trouble. 
In support of this opinion, I must be permitted to say again that in 
my own practice deformity after this fracture is the exception. I never 
apprehend its occurrence unless there is comminution, or other serious 
complications. 

In other, and somewhat exceptional cases where the lower fragment is 
driven back until its broken surface overrides the broken surface of the 
upper fragment, and in addition to the consequent impaction there is 
added a lifting of the periosteum, as described by Pilcher, we must first, 
as stated by him, increase the dorsal flexion, press the finger against the 
proximal end of the lower fragment, and then, while making extension 
from the hand, gradually bring the hand and the lower fragment forward. 
And I may add that if, by the method of direct and forcible pressure 
from behind, or by Pilcher's modification of this method, we have once 
brought the lower fragment thoroughly into place, it will remain in place 
with little or no retentive apparatus ; unless, indeed, the lower fragment 
be comminuted, in which case some degree of deformity will ensue 
Avhatever plan of treatment we may adopt. In case the ulna is dislocated 
also, and is imprisoned by the annular ligament, circumduction with ex- 
tension, as practised by Dr. Moore, and heretofore described, will be 
required. 

It only remains for us to determine the precise form of splint which 
ought to be preferred, and to describe its mode of application. The nar- 
row "attelle cubitale" of Dupuytren is inconvenient; nor can I give the 
preference to the curved dorsal splint recommended by Nelaton, and em- 
ployed by Robert Smith, Erichsen, and others. It is not to me a matter 
of entire indifference, in case only one curved splint is employed, whether 
this be applied to the palmar or dorsal surface of the forearm. Foreign 
surgeons, so far as I know, have applied this splint to the dorsal surface, 



FRACTURES OF THE RADIUS. 293 

and the straight splint to the palmar ; while American surgeons have 
adopted almost as uniformly the opposite rule — to whose practice, in this 
respect, I acknowledge myself also partial. It is to the curved splint 
rather than to the straight that we mainly trust ; not simply, or at all, 
perhaps, because of its form, but because the curved splint is also the 
long splint. This is the splint, therefore, which ought to be the most 
steady and immovable in its position. Now, the very irregularities of 
surface upon the palmar aspect of the forearm and hand, instead of con- 
stituting an embarrassment, enable us, when the splint is suitably pre- 
pared and adjusted, to fix it more securely. Moreover, upon it alone, 
after a few days, the surgeon may see fit to rely, and in that case it ought 
to be applied to that surface of the arm which is most tolerant of con- 
tinued pressure. The palmar surface, as being more muscular, and as 
having been more accustomed to friction and to pressure, must necessarily 
have the advantage in this respect. The palmar splint terminating also 
at the metacarpophalangeal articulations, instead of at the wrist, as the 
short straight splint must do when the hand is adducted, enables the 
hand to be flexed upon its extremity over a hand-block, or pad of proper 
size. Such are the not insignificant advantages which we claim for this 
mode over that pursued by our transatlantic brethren. The block, sug- 
gested first by Bond, of Philadelphia, is a valuable addition, since the 
flexed position is always more easy for the fingers, and in case of anky- 
losis this position renders the whole hand more useful. 

[Gordon's splint is very highly commended by Irish surgeons, but it is not 
in use in this country. It "consists of the body, the ulnar, and bevelled .por- 
tions, with a curved back splint (Fig. 159). The lower end of the ulnar portion 
is curved forward, and hollowed to receive the inner border of the flexed hand, 
with a slit for the carpal strap. The bevelled portion is secured to the body of 

Fig. 159. 




C 

Gordon's splint. B. The palmar splint. C. The dorsal splint. A. The splints applied. 

the splint nearly half an inch internal to its margin ; it is cut off obliquely from 
without inward and from below upward; it is applied to the palmar surface of 
the upper fragment, which it is its office to fix. The lower end of the back 
splint is much curved forward. The curve, with a thick pad, is necessary to 
enable it to press the base of the metacarpus, the carpus, and the lower end of 

1 Bryant, Prac. of Surgery, 4th ed., p. 880. 



294 



FRACTURES OF THE RADIUS. 



the lower fragment well forward for the restoration of the natural aspect of the 
carpal surface and the concavity of the radius."] 

Levis employs a splint made of copper, lined with tin, and furnished with a 
series of little pointed elevations along the edges to prevent the bandage from 
slipping. 1 No doubt this splint would answer its purpose well in case it fitted 
accurately; but to insure this the surgeon must be supplied with a considerable 
number, differing materially in length, breadth, and form ; or it must be made 
for the patient who is under treatment. I have occasionally employed a splint 




Levis's metallic splint. 

of this form ; once when I had broken my own wrist — a Colles's fracture — and 
with admirable results; but I have always used for this purpose a pretty thick 
sheet of gutta-percha, which in a few minutes can be fitted with the most abso- 
lute accuracy. Gum-shellac cloth can be adapted, after thorough soaking in 
boiling-hot water, with nearly the same degree of accuracy, and I think sole- 
leather might also ; but in the latter case, after being moulded it would have to 
be laid aside to dry and harden. 

In most cases I prepare extemporaneously a splint from a wooden 
shingle, which I first cut into the requisite shape and length ; the length 
being obtained by measuring from the front of the elbow-joint, when the 
arm is flexed to a right angle, to the metacarpophalangeal articulations, 



Fig. 161. 




Author's palmar splint; right arm. 



Fig. 162. 



Author's dorsal splint; frequently omitted. 



the fingers being first flexed. It ought, indeed, to fall half an inch short 
of the bend of the elbow, to render it certain that it shall make no un- 
comfortable pressure at this point ; and the direction to measure with 
the arm flexed is of sufficient importance to warrant a repetition. The 
breadth of the splint should be in all its extent just equal to the breadth 



Levis, R. J. (pamphlet without date). 



FRACTURES OF THE RADIUS. 



295 



of the forearm in its widest part, except where it is to receive the ball of 
the thumb, so that there shall be no lateral pressure upon the bones. If 
the splint is of unequal breadth, 



Fig. If 




the roller cannot be so neatly ap- 
plied, and it is more likely to be- 
come disarranged. Thus construc- 
ted, it is to be covered with a sack 
of cotton-cloth, made to fit moder- 
ately tight, with the seam along its 
back, and afterward stuffed with 
cotton-batting or with curled hair. 
These materials may be pushed in, 
and easily adjusted, wherever they 
are most needed, from the open 
extremities of the sack. While 
preparing, the splint must be occa- 
sionally applied to the arm until it 
fits accurately every part of the 
forearm and hand, only that the 
stuffing must be more firm a little 
above the lower end of the upper 
fragment, and in the hollow of the 
hand. Between these two points 
there should be little or no cotton. 
The open ends of the sack are then 
to be neatly stitched over the ends 
of the splint, after which the splint 
may be laid directly upon the skin 
without any intermediate com- 
presses or rollers. The advantages 

of this form of splint are easily comprehended. They consist in facility 
and cheapness of construction, accuracy of adaptation, neatness, perma- 
nency, and fitness to the ends proposed. There is also no possibility 
of making painful or injurious pressure upon the arteries or nerves 
which lie upon the front of the wrist, j 

The extemporaneous splint recommended by Dr. Isaac Hays, of Philadelphia, 
is very similar, but it lacks the neatness and permanency of that which I have 
now described. 

In most cases it is better to employ, also, at least during the first fort- 
night, a straight dorsal splint, of the same breadth as the palmar splint, 
and of sufficient length to extend from the elbow to the middle of the 
carpus. This should be covered and stuffed in the same manner as the 
palmar splint, except that here the thickest and firmest part of the splint 
must be opposite the carpus and the lower fragment. 

Having restored the fragment to place by some one of the methods 
already described, the arm is to be flexed upon the body, and placed in 
a position of semi-pronation ; when the splints are to be applied, and 
secured with a sufficient number of turns of the roller, taking especial 



The author's dressing complete. The curved 
palmar splint is not in view, only the dor- 
sal. The faint white lines represent the 
roller. The sling is omitted, for the purpose 
of bringing the other dressings into view. 



296 FRACTURES OF THE RADIUS. 

care not to include the thumb, the forcible confinement of which is 
always painful and never useful. 

Let me repeat that, in most cases, all of our success will depend not 
so much upon the particular form of apparatus employed as upon whether 
we have properly reduced the fracture in the early stage of the accident. 
When once reduced it is, with rare exceptions, easily kept in place. 

I cannot too severely reprobate the practice of violent extension of 
the wrist in the efforts at reduction, when no overlapping or impaction 
of the fragments exists and the ulna is not dislocated ; and that, whether 
this extension be applied in a straight line or with the hand adducted. 
It has been shown that in a great majority of cases no indication in 
this direction is to be accomplished; and to pull violently, under these 
circumstances, upon the wrist, is not only useless, but hurtful. It is 
adding to the fracture, and to the other injuries already received, the 
graver pathological lesion of a stretching, a sprain of all the ligaments 
connected with the joint. I am persuaded that to this violence, added 
to the unequal and too firm pressure of the splints, is, in a great meas- 
ure, to be attributed the subsequent inflammation and ankylosis in very 
many cases. 

The first application of the bandages ought to be only moderately 
tight, and as the application and swelling develop in these structures 
with rapidity, the bandages should be attentively watched, and loosened 
as soon as they become painful. It must be constantly borne in mind 
that, to prevent and control inflammation in this fracture, is the most 
difficult and by far the most important object to be accomplished, while 
to retain the fragments in place, when once reduced, is comparatively 
easy. During the first seven or ten days, therefore, these cases demand 
the most assiduous attention : and we had much better dispense with the 
splints entirely, as advised by Fauger, than to retain them at the risk of 
increasing the inflammatory action. 

Indeed, I have no doubt that very many cases would come to a successful 
termination without splints, if only the hand and arm were kept perfectly still 
in a suitable position until bony union was effected. I must also enter my pro- 
test against many or all of those carved splints which are manufactured, hawked 
about the country, and sold by mechanics who are not surgeons; with a fossa 
for each styloid process, a ridge to press between the bones, and various other 
curious provisions for supposed necessities, but which never find in any arm 
their exact counterparts, and only deceive the inexperienced surgeon into 
neglect of the proper means for making a suitable adaptation. They are the 
fruitful sources of excoriations, ulcerations, inflammations, and deformities. 

[Swinburne, of Albany, employed a form of dressing which has had some 
advocates. He proposed its use in all fractures of the lower end of the radius. 
It consisted of a single splint, a thin piece of wood, extending from the elbow to 
the metacarpophalangeal joints on the posterior aspect the width of the limb; 
two compresses are provided, one for the concavity of the carpus, and the other 
for the deficiency of the muscles in the arm above; adhesive strips are em- 
ployed for fastening the splint to the arm, commencing above, and being repeated 
at intervals to the hand; the displaced bones are properly reduced before the 
strips are applied. The following illustrations (Figs. 164, 165, 166) show the 
application of the dressing and appearance of the limb. 

In reference to the treatment of these fractures, the following cases 
and the accompanying remarks, by that great surgeon, Dupuytren, are 
too pertinent not to merit a place in every treatise of this character. 



FRACTURES OF THE RADIUS. 



297 



" The two succeeding cases are not only interesting as fractures of the radius, 
but they are further deserving of attentive consideration, on account of the 
serious complications which accompanied them, aud which were the consequence 

Fig. Ifi4. 




Posterior aspect of arm. 
Fig. 165. 




The two compresses. 

of forgetting an important precept. More than once, indeed, it has occurred 
that the surgeons have been so intent on preserving fractures in their proper 
position that the extreme constriction employed has actually caused destruction 
of the soft parts. A piece of advice which I have very frequently given, and 
which I cannot too often repeat, is to avoid tightening too much the apparatus 
for fractures during the first i'ew days of its being worn ; for the swelling which 
supervenes is always accompanied by considerable pain, and may be followed 
by gangrene. It cannot, therefore, be too urgently impressed on young practi- 
tioners, to pay attention to the complaints which patients make ; and to visit 
them twice daily, and relax the bandages and straps as need may be, in order to 
obviate the frightful consequences which may spring from not heeding this 
necessary precaution ; by carefully attending to this point I have been saved the 
painful alternative of ever having to sacrifice a limb for complications which its 
neglect may entail. 

"A. R., set. 44, fractured his right radius while going down into a cellar. 
When the fracture was reduced (it was near the base of the bone) an apparatus 
was applied, but fastened too tightly ; and, notwithstanding the great swelling 
and the acute pain which the patient endured, it was not removed until the 
fourth day, when the hand was cold and oedematous, and the forearm red, pain- 
ful, and covered with vesications. Leeches, poultices, and fomentations were 
applied, and followed by some alleviation of the local symptoms, though there 
was much constitutional disturbance. At the close of a fortnight from the acci- 
dent, the palmar surface of the forearm presented a point where fluctuation was 
supposed to exist; but when a bistoury was plunged into it no matter followed. 
Portions of the flexor muscles subsequently sloughed, and the skin mortified. 
The only resource was amputation, which was performed above the elbow six 
weeks after his admission ; and he afterward recovered without the occurrence 
of any further untoward symptoms. 

" R., set. 36, was at work boring an artesian well when he was struck by part 
of the machinery on the right arm; he was instantly knocked down and thrown 
violently on the right thigh. A surgeon who was sent for detected a fracture of 
the radius, and applied the usual apparatus, consisting of pads and splints, con- 
fined by a roller extending from the extremities of the fingers to the elbow, 



298 FRACTURES OF THE RADIUS. 

which compressed the arm so tightly as to give rise to very great suffering. 
The fingers, hand, and forearm were numbed almost to insensibility, and yet 
the surgeon in attendance did not think proper to loosen the apparatus. Such 
was the condition of the patient until he came to the Hotel Dieu, four days 
after the accident; the fingers were then black, cold and insensible, and when I 
removed the splints I found the hand likewise black, especially on its palmar 
surface. On the twelfth day amputation was performed at the elbow-joint; but 
the patient did not survive the operation more than ten days, the immediate 
cause of death being acute pleurisy. 

" The above case presents a painful illustration of the neglect to which I have 
alluded. In nearly every instance the swelling of the limb requires that careful 
attention should be paid to the bandage or straps by which the apparatus is 
confined. Similar accidents are likely to result from the employment of an im- 
movable apparatus, of which an example occurred in the practice of M. Thierry, 
one of my pupils. He was summoned to visit a young girl, on whom such an 
apparatus had been applied for supposed fracture of the radius. After suffering 
excruciating torment, the forearm mortified, and amputation was the only 
resource ; on examining the limb, no trace of fracture could be discovered. 
Had a simple apparatus been here employed, and properly watched, the patient's 
limb would not have been sacrificed.'' 1 

Eobert Smith mentions, also, the case of a boy, set. 18, who had a fracture of 
the lower extremity of the radius, through the line of the junction of the epi- 
physis with the diaphysis, caused by being thrown from a horse. A surgeon 
applied, within an hour, a narrow roller tightly around the wrist. On the fol- 
lowing day the limb was intensely painful, cold and discolored; still the roller 
was not removed, nor even slackened. On the fourth day he was admitted into 
the Richmond Hospital, when the gangrene had reached the forearm. Spon- 
taneous separation of the soft parts finally occurred, and the bones were sawn 
through twenty-four days after the fracture was produced, from which time 
''everything proceeded favorably." 2 

Nov. 21, 1851, a boy, ten years old, living in the town of Andover, Mass., had 
his left hand drawn into the picker of a woollen mill, producing several severe 
wounds of the hand and a fracture of the radius near its middle. One of the 
wounds was situated directly over the point of fracture, but whether it com- 
municated with the bone or not was not ascertained. A surgeon was called, 
who closed the wounds, covered the forearm with a bandage from the hand to 
above the elbow, and applied compresses and splints. The lad made no com- 
plaint, his appetite remaining good, and his sleep continuing undisturbed until 
the third day, when he began to speak of a pain in his shoulder; on the same 
day also it was noticed that his hand was rather insensible to the prick of a pin. 
Early on the morning of the fourth day his surgeon, being summoned, found 
him suffering more pain and quite restless ; and on removing the dressings, the 
arm was discovered to be insensible and actually mortified from the shoulder 
downward. On the sixth day a line of demarcation commenced across the 
shoulder, and on the twenty-first day the father himself removed the arm from 
the body by merely separating the dead tissues with a feather. Subsequently a 
surgeon found the head of the humerus remaining in the socket, and removed 
it, the epiphysis having become separated from the diaphysis. The boy now 
rapidly got well. This case became the subject of a legal investigation. Dr. 
Pilsbury, of Lowell, Mass., declared that in his opinion this unfortunate result 
had been caused by too tight bandaging, and by neglecting to examine the arm 
during four days. On the other hand, I)rs. Hayward, Bigelow, Townsend, and 
Ainsworth, of Boston, with Kimball, of Lowell, Drs. Loring and Pierce, of 
Salem, believed that the death of the limb was due to some injury done to the 
artery near the shoulder-joint; and in no other way could they explain the total 
absence of pain during the first two days ; nor could they regard this condition 
as consistent with the supposition that the bandage occasioned the death of the 
limb. 3 

1 Dupuytren, Injuries and Diseases of Bones, Syd. ed., London, 1847, pp. 145-7. 

2 R. Smith. Treatise on Fractures, etc., Dublin, 1854, p. 170. 

3 Boston Med. and Surg. Journ., vol. xlviii. p. 281. 



FRACTURES OF THE RADIUS. 299 

I cannot but think, however, that these gentlemen were mistaken, and that 
the gangrene was alone due to the bandages. In a similar case which came 
under my own observation, and in which both the radius and ulna were broken, 
the roller extended no higher than just above the elbow, and the patient com- 
plained of no pain until the bandages were unloosed, yet the arm separated at 
the shoulder-joint. I shall refer again to this example in the chapter on 
Fractures of the Radius and Ulna ; and shall take occasion then also to speak 
more fully ot the causes of these terrible accidents. 

Norris mentions another case of compound fracture of the lower end of the 
radius which came under his notice at the Pennsylvania Hospital in August, 
1837, the arm having been dressed by a surgeon within half an hour after the 
accident, with bandages and splints. When these bandages were removed at 
the hospital, on the fifth day, " the soft parts around the fracture were found to 
have sloughed, an abscess extended up to the elbow-joint, and sloughs existed 
over the condyle. Severe constitutional symptoms arose, making amputation 
of the arm necessary." 1 

A lady, set. 50, was also seen by Thierry, who, having broken the radius 
near its lower end, lost her fingers by the sloughing consequent upon a tight 
bandage. 2 

A woman was admitted into one of Dr. Wood's wards in the Bellevue Hos- 
pital about the 1st of February, 1863, who had fallen upon her hand a few days 
before and broken the radius just above the wrist. Her arm was dressed with 
splints and bandages at one of the dispensaries in this city. Gangrene ensued, 
and when I saw her on the 8th of February, the death had extended to the 
middle of the forearm, the dead tissues being dry and black. Dr. Wood ampu- 
tated the arm, but she died. 

The remarks which have now been made in relation to the treatment 
of Colles's fracture are applicable, with only such slight modifications 
as would naturally be suggested, to fractures of the lower end of the 
radius commencing upon the radial side of the bone and extending 
obliquely downward into the joint (perhaps, indeed, this ought to be 
regarded as a variety of Colles's fracture) ; and it is to this form of frac- 
ture, especially, that the pistol-shaped splint must be found applicable. 
If the fracture actually extends into the joint, it must not be forgotten 
that, in order to the prevention of ankylosis, the wrist should be early 
subjected to passive motion. 

The following example of a compound comminuted fracture of the radius may 
serve to illustrate the value of a mode of treatment under certain circumstances : 
W. C, set. 30 ; a large piece of iron casting fell upon his arm, crushing and 
lacerating the wrist, and comminuting the lower part of the radius. I found the 
whole of the soft parts torn away in front of the joint, and the fragments of the 
radius projected into the flesh in every direction. The hope of saving the hand 
seemed to be scarcely sufficient to warrant the attempt; at least by the ordinary 
mode of procedure. I, however, believed it could be saved if, having removed 
the fragments of the radius, I practised resection of the lower end of the ulna, 
and allowed the muscles to become completely relaxed. Accordingly, after 
placing him under the influence of chloroform, I enlarged the wounds so as to 
enable me to remove six or seven fragments of the radius, leaving others which 
were broken off but not much displaced. I then removed with the saw one inch 
and a half of the ulna. The hand was immediately drawn up by the contraction 
of the remaining muscles, but their tension was completely relieved. The wounds 
were closed and dressed lightly, and the whole limb was placed on a broad and 
well-padded splint covered with oil-cloth. The hand, which was very pale and 
exsanguine, was covered with warm cotton-batting. His recovery was rapid and 
complete, nor was there at any time excessive inflammation in the limb. I 

1 Norris, note to Liston's Surgery, p. 54. 

2 Amer. Journ. Med. Sci., vol. xxv. p. 461, from L'Experience for 1838. 



300 FRACTURES OF THE RADIUS. 

have seen this man frequently since he left the hospital, and while he has 
recovered only a little motion in the wrist-joint, his hand and fingers are nearly 
as useful as before the accident. He is able to perform all ordinary kinds of 
labor with almost as much ease as most other men; and, what is always grati- 
fying to the humane surgeon, he does not fail to appreciate fully the service 
which has been conferred upon him by the preservation of his mutilated hand. 
I have recently adopted the same treatment with equal success in a case of 
gunshot wound of the lower end of the radius. 

[Harte, 3 of Philadelphia, has performed osteotomy for vicious union of this 
fracture with good results. He operated antiseptically, making an incision along 
the inner margin of the extensor carpi radialis tendons, and then applying the 
chisel. Duplay has also operated for the same deformity.] 

Fracture of the Styloid Process of the Radius Independently of a 
Colles's Fracture. — Dr. Butler, of the Brooklyn Hospital, reports a case 
treated by Dr. J. C. Hutchison of fracture of the right radius at the 
junction of the middle and lower thirds, accompanied with a fracture also 
of the styloid apophysis in the above bone. 

The accident occurred in a lad fourteen years old, who had fallen from a height 
of thirty feet upon the pavement. The lower fracture commenced at the base 
of the styloid process of the radius, and extended down obliquely into the wrist- 
joint, breaking off about one-fifth of the articular surface. The process was 
drawn up on the posterior surface of the radius, about one inch and a half, by 
the supinator radii longus muscle. It was movable, but, in consequence of the 
contusion and swelling, could not be returned to its place. The hand occupied 
the same position that it does in Colles's fracture. On the eighth day an attempt 
was made to force down the process with a compress secured by adhesive plaster 
straps ; but it could not be done. The hand and arm were confined also to a 
pistol-shaped splint ; ulcerations ensued from the pressure of the compress, and 
the process was laid bare, but it finally became united in its abnormal position ; 
the motions of the wrist, however, were not impaired, and the power of prona- 
tion and supination soon returned.' 2 

A lady called upon me having a fracture of the styloid process of the radius, 
which had occurred about four months previously. The fragment was tilted 
forward and carried slightly upward by the action of the long supinator. It was 
movable. The motions of the joint were in no way interfered with, and the form 
of the wrist was natural. She was somewhat advanced in life, and suffered from 
pains and soreness about the joint, but no more than is usual after severe wrist- 
joint injuries. The character of the accident was not recognized by her surgeon, 
and no treatment had been adopted ; nor is it to be supposed that the displace- 
ment could have been remedied, except by section of the tendon of the long 
supinator, if its existence had been recognized ; and, if this had been done, I 
doubt whether she would have had a more useful arm than she has now. 

Dr. Wm. Hunt, 3 of Philadelphia, reported a case of this fracture, the result 
of a fall upon the hand, and accompanied with considerable comminution. It 
became necessary to amputate the arm, and the opportunity was thus afforded 
to determine the exact nature of the lesion by dissection. 

Epiphyseal Separations. — This bone is formed from three centres, 
namely, one for the shaft and one for either extremity. The shaft is 
ossified at birth. About the end of the second year ossification com- 
mences in the lower epiphysis, and it becomes united to the shaft at 
about the twentieth year. The same process commences in the upper 
epiphysis at about the fifth year, and is completed by consolidation with 
the shaft at the age of puberty. 

1 Univ. Med. Mag., Aug. 1887. 

2 New York Journ. of Med , 1857. 

:i Hunt, Phil. Med. Times, Oct. 9, 1880, p. 26. 



FRACTURES OF THE RADIUS. 



301 



I have met with no recorded examples of separation of the upper 
epiphysis, and the examples of separation of the lower epiphysis have 
seldom been clearly made out. I have already mentioned one as having 
been reported by Robert Smith. He speaks also of other cases occurring 
in conjunction with a separation of the lower end of the ulna, and 
which, he thinks, are liable to be mistaken for dislocations. 1 



Fig. 167 



Fig. 168. 





Y 



Vertical section of radius and soft parts, showing separa- 
tion and backward displacement of the lower epiphysis of 
the radius. (Bryant.) 

Malgaigne says that we have reasons to suspect this 
accident when the fracture occurs in persons under 
twenty years of age. Cloquet ascertained its existence 
by a dissection in a child of twelve years ; Roux also 
in a child whose age is not given, and Voillemier 
produced it easily in the dead bodies of children, 
and once in the body of a robust man of twenty- 
four. 2 Schmidt 3 and Girdner 4 have also noticed the 
frequency of the epiphyseal separation when, in the 
case of infants, the fracture is caused by avulsion 
upon the cadaver. The experiments of Dr. Girdner, 
made at my request, also showed that in early life 
avulsion sometimes caused a fracture just above the 
epiphysis, sometimes a bending of the bone, without 
fracture, and sometimes only a rupture of the liga- 
ments. I think I have broken the radius at the epiphyseal junction in some of 
my- experiments of forced flexion in adult females. 

[Moullin, 5 of London, reports a case of separation of the upper epiphysis of 
the radius in a boy sixteen years of age. Amputation was performed. The 
upper epiphysis was completely detached, the line of separation passing between 
the cartilage and the diaphysis. Bryant, of London, gives an illustration of a 
separation of the lower epiphysis backward. The patient was a boy aged ten 
years. (Fig. 168.)] 

The treatment of this accident will not demand any special considera- 
tion, since it will not differ essentially from the treatment required in a 
fracture occurring at the same point. 

Delayed or Non-union of Fractures of the Radius.— Muhlenburg in his 
tables has recorded 23 cases, of which It are reported as having been cured, and 
in 6 the attempts to cure have failed. Resection and drilling furnish the largest 
percentage of cures. I have never met with an example of non-union in a frac- 
ture of the lower end of the radius. 



Radius with epiphyses. 
(From Gray.) 



1 Robert Smith, op. cit., p. 164. 

2 Malfjaicue, op. cit. 

3 Schmidt. These de Paris, 1878. Xo. 114. 

i Girdner. Jno. H., Med Record, Feb. 26, 1881. 
5 Trans. Path. Soc , Lond., vol. xxxix., 188S. 



302 FRACTURES OF THE ULNA. 



CHAPTEE XXIII. 

FRACTURES OF THE ULNA. 

§ 1. Fractures of the Olecranon Process. 

Causes. — My records furnish me with accounts of only nineteen of 
these fractures, and, so far as I have been able to ascertain, all were oc- 
casioned by falls upon the elbow, or by blows inflicted directly upon the 
part. Malgaigne has, however, been able to collect accounts of six 
examples of fracture of the olecranon, produced, as is affirmed, by the 
violent action of the triceps ; as in pushing with the arm slightly flexed, 
in throwing a ball, in plunging into the water with the arms extended, 
etc. ; but only four of these reported examples does he think are suffi- 
ciently authenticated to entitle them to be received as facts ; nor do I 
think it possible to affirm positively that in any instance, where the whole 
process is broken off, the triceps alone has occasioned the separation. 

For example, Capiomont reports the case of a cavalier, who, being intoxicated, 
was thrown head-foremost from his horse, and, striking probably upon his head, 
was found to have broken the olecranon process. We do not, in this example, 
see evidence alone of a forcible contraction of the triceps, but also of violent 
pressure against the hand and in the direction of the axis of the forearm toward 
the elbow-joint, by which the olecranon process might have been so thrown for- 
ward against the fossa of the humerus as to cause its separation. The same 
explanation might apply to several of the other examples. 

Point and Direction of Fracture ; Displacement, etc. — The process 
may be broken at its summit, at it base, or intermediate between these 
two extremes, the last of which is the most common. It is probable that 
when the action of the triceps alone has produced the fracture, it will be 
found that only that portion which receives the insertion of the triceps 
has been broken off. 

Malgaigne, who has been able to find upon record only two cases of a fracture 
of the extreme end of the process, declares that they were both occasioned by 
muscular action. 

Fractures of the middle are generally transverse, or only slightly 
oblique, occurring in the line of the junction of the epiphysis with the 
diaphysis. Fractures through the base are generally quite oblique, the 
line of fracture extending from before downward and backward, so that 
not only the whole of the process, but a portion of the back of the shaft 
is carried away ; and this accident can scarcely happen, except by a blow 
received upon the front and lower end of the humerus, while the arm is 
extended ; or by a blow upon the back of the forearm, whether the arm 
be in a position of flexion or extension, received at a point a little below 
where the shaft of the ulna joins the olecranon. 



FRACTURES OF THE OLECRANON PROCESS. 303 

[Lloyd, 1 of Birmingham, describes a form of fracture of the olecranon which 
narrows the great sigmoid notch and obstructs the reduction of a dislocated 
elbow. The case came under his care about ten months after a fall from a 
bicycle. The limb was in such condition as to require the operation of excision 
of the lower, broken end of the humerus. It was found, however, that there was a 
dislocation of the ulna and radius backward, and a fracture of the olecranon. This 
fracture ran transversely across the superior surface of the process, nearly an 
inch from its extremity, corresponding closely to the anterior edge of the inser- 
tion of the triceps tendon. The fracture extended obliquely downward and for- 
ward, and ended in the great sigmoid notch at its deepest part, the articular 
surface being thereby divided into two nearly equal halves. Another fracture 
appeared to have passed from a point half an inch nearer the olecranon tip to 
join the first fracture at about its centre, separating a small triangular piece 
from the posterior angle of the whole fragment. This wedge-shaped fragment 
had been driven downward and forward into the notch, so as to narrow it to a 
mere cleft, reducing its longitudinal diameter from three-fourths to one-fourth 
of an inch. 

Mr. Lloyd states that from a study of the specimen, it is evident that the man 
must have fallen upon the extreme top of the olecranon with the joint in acute 
flexion, andthat the same force which detached the fragment drove it forward 
into the sigmoid notch, thrusting the humerus out of the articulation, and breaking 
it across just above the condyles. An exact 

diagnosis would be a matter of extreme Fig. 169. 

uncertainty. The most suggestive symp- 
toms are: the imposibility of reduction, 
the absence of the characteristic sharp 
outlines of the top of the olecranon, the 
shortening of the ulna measured from the 
top of the olecranon to the styloid pro- 
cess. He thinks the parts might have 
been moulded into position under an 
anaesthetic shortly after the injury.] 

The only displacement to which 
the upper fragment seems to be lia- 
ble, is in the direction of the triceps ; Fracture of the olecranon at its base. 

and the degree of this displacement 

does not depend so much upon the point at which the fracture has taken 
place as upon the violence which has occasioned it, the extent of the dis- 
ruption of the ligaments, aponeurosis of the triceps and of the capsule, 
and upon whether, since the accident, the arm has been flexed or kept 
extended. 

In five instances I have found distinct crepitus immediately after the 
fracture had occurred, produced by only moving the fragment laterally, 
showing plainly that little or no displacement had taken place. 

The following example will show also that this displacement does not always 
happen even after the lapse of several days, and where no surgical treatment has 
been adopted. S. D,, set. 14, fell upon the point of the elbow, and two days 
after was admitted to the Buffalo Hospital of the Sisters of Charity. The 
elbow was then much swollen, but no crepitus could be detected, and he could 
nearly straighten his arm by the action of the triceps. On the sixth day, the 
swelling having sufficiently subsided, a distinct crepitus was discovered when 
the olecranon process was seized between the fingers and moved laterally. We 
extended the arm immediately, and applied a long gutta-percha splint to the 
whole front of the arm and forearm, securing it in place with a roller. On the 
eleventh day, five days after the first dressing, the splint was taken off and its 

1 London Lancet, May 5, 1888. 




304 FEACTURES OF THE ULNA. 

angle at the elbow-joint slightly changed ; and this was repeated every day 
until the twenty-second from the time of the accident. The splint was then 
finally removed, when the fragment was found to be united without any per- 
ceptible displacement, and the motions of the joint were unimpaired. 

It must not be inferred that it is always prudent to leave this fracture 
thus unsupported, since it has occasionally happened that the displace- 
ment, which did not exist at first, has taken place to the extent of half 
an inch or more, after the lapse of several days. Mr. Earle mentions a 
case in which the separation did not take place until the sixth day, when 
it was occasioned by the patient's attempting to tie his neckcloth. 

Symptoms. — The usual signs of a fracture of the olecranon process 
are, when the fragments are not separated, crepitus, discovered especially 
by seizing the process and moving it laterally ; or, when displacement 
has actually taken place, the crepitus may be discovered sometimes by 
extending the forearm, and pressing the upper fragment downward until 
it is made to touch the lower fragment ; the existence of a palpable 
depression between the fragments, partial flexion of the forearm, and 
inability on the part of the patient to straighten it completely, or even 
to flex the arm in some cases. If the fragments do not separate, gentle 
flexion and extension of the arm, while the finger rests upon the process, 
may enable us to detect the fracture. 

It w T ill sometimes happen that, owing to the rapid occurrence of tume- 
faction, the evidence of a fracture will be quite equivocal ; and, in all 
cases where a severe injury has been inflicted upon the point of the 
elbow, it will be well to suspend judgment until, by repeated examina- 
tions, made on successive days, the question is determined. Meanwhile, 
the arm ought to be kept constantly in an extended position, as if a frac- 
ture was known to exist. 

Prognosis. — In a large majority of cases this process becomes reunited 
to the shaft by ligament, which may vary in length from a line to an 
inch or more, and which is more or less perfect in different cases. Some- 
times it is composed of two separate bands, w T ith an intermediate space, 
or the ligament may have several holes in it ; at other times it is com- 
posed in part of bone and in part of fibrous tissue ; but most frequently 
it is a single, firm, fibrous cord, whose breadth and thickness are less 
than those of the process to -which it is attached. If the fragments are 
maintained in perfect apposition, a bony union may occur, yet it is not 
invariably found to have taken place, even under these circumstances. 

[Macewen, 1 of Glasgow, attributes failure to obtain bony union of the ole- 
cranon to the interposition of shreds of fibrous tissue between the bones, as in 
fracture of the patella.] 

Malgaigne thinks, also, he has seen one case, in which there was neither bone 
nor fibrous tissue deposited between the fragments. This was an ancient frac- 
ture at the base of the olecranon; the superior fragment remained immovable 
during the flexion and extension of the arm, yet it could be moved easily from 
side to side. 

In my own cases I have five times found the fragments united without any 
appreciable separation, and have presumed that the union was bony. One of 
these examples I have already mentioned ; the second was in the person of a 
lady, aged about forty years, who, having fallen down a flight of steps, I found 

1 Annals of Surgery, vol. v., 1887. 



FRACTURES OF THE OLECRANON PROCESS. 



305 




a large bloody tumor covering the elbow-joint, but there was no difficulty in 

detecting a fracture of the olecranon process. It was easily moved from side to 

side, and this motion was accompanied with a distinct crepitus. During the 

first week the arm was only laid upon a pillow, but as it 

was found to become gradually more flexed, and the swell- Fig. 170. 

ing having in a great measure subsided, the arm was nearly, 

but not quite, straightened, and a long gutta-percha splint 

applied to the palmar surface of the forearm and arm. 

The fragments united in about twenty or twenty-five days, 

and without separation, so far as could be discovered in a 

very careful examination. 

The third example to which I have referred, occurred 
in a boy fourteen years old, and was treated by Dr. Ben- 
jamin Smith, of Berkshire, Massachusetts. Sixty-nine 
years after, he being then eighty-three years old, I found 
the olecranon process united apparently by bone, but to 
that day he had been unable to straighten the arm com- 
pletely, or to supine it freely. 

In one instance I found the fragment, after the lapse of 
one year, united by a ligament, which seemed to be about 
one-quarter of an inch in length, and the arm appeared to 
be in all respects as perfect as the other. He could flex 
and extend it freely. 

In the two following examples, also, the bond of union 
was ligamentous : 

J. C. , set. 18, having broken the olecranon, it was treated Union by ligament. 
with a straight splint. Nine years after, I found the 

process united by a ligament half an inch in length, and he could nearly, but 
not entirely, straighten the arm. In all other respects the functions and 
motions of the arm were perfect. 

A lad, set. 15, was brought to me, whose olecranon process had been broken 
by a fall six months before, and at the same time the head of the radius had 
been dislocated forward. I found the radius in place, and the olecranon 
process united by a ligament about half an inch in length. He was not able to 
straighten the arm completely, the forearm remaining at an angle of 45° with 
the arm. 

Treatment. — It will surprise the student who is yet unacquainted with 
the literature of our science, to learn that in relation to the treatment 
of a fracture of the olecranon process a wide difference of opinion has 
been entertained as to what ought to be the position of the arm and the 
foiearm, in order to the accomplishment of the most favorable results; 
and that, while some insist upon the straight position as essential to 
success, others prefer a slightly flexed position, and still others have 
advocated the right-angled position. 

Thus Hippocrates, and nearly all of the earlier surgeons, down to a period so 
late as the latter part of the last century, directed that the arm should be placed 
in a position of semiflexion ; Boyer, Desault, and, after them, most of the 
French surgeons of our own day, prefer a position in which the forearm is very 
slightly bent upon the arm ; while Sir Astley Cooper, and a large majority of 
the English and American surgeons, employ complete or extreme extension. 

The arguments presented by the advocates and antagonists of these 
various plans deserve a moment's consideration. In favor of the posi- 
tion of semiflexion, requiring no splints, and, in the opinion of some 
writers, not even a bandage, but only a sling to support the forearm, it 
is claimed that it leaves the patient at liberty at once to walk about and 
to move the elbow-joint freely, so soon at least as the subsidence of the 

20 



306 FRACTURES OF THE ULNA. 

swelling and pain will permit, and that in this way the danger of anky- 
losis is greatly diminished ; that, moreover, if ankylosis should unfor- 
tunately occur, the limb is in a much better position for the proper per- 
formance of its most ordinary functions than if it were extended. Some 
have also added to this argument a statement that a fibrous union, under 
any circumstances, is inevitable, and that it is a matter of little conse- 
quence whether the ligament thus formed is long or short, since in either 
condition it will be equally serviceable. 

In reply to these statements, it may be said briefly that they are nearly 
all based upon false premises, or that they have been proved in them- 
selves to be essentially erroneous. Ankylosis is always a serious event, 
which by all possible means the surgeon will seek to prevent, but posi- 
tion has nothing to do with determining this result ; when it does occur, 
it may usually be ascribed either to the severity and complications of the 
original injury, to the violence of the consequent inflammation, or to 
having neglected, at a proper period and with sufficient perseverance, to 
move the joint. That a fibrous union is inevitable under any circum- 
stances, has been proved to be an error ; and while a short ligamentous 
union, such as is usually obtained when the arm is kept straight, may 
serve its purposes quite as well as a bony union, yet a long fibrous union, 
such as must very often be obtained when the arm is kept at a right 
angle, would seriously impair the usefulness of the limb. 

The only argument which remains, and which really possesses any 
weight, is, that, if permanent ankylosis does not actually occur, the arm, 
when semi-flexed, is in a better position for the performance of its ordi- 
nary functions ; and this, considered as an argument in favor of the 
universal or even general adoption of the flexed position, is successfully 
met by a statement of the infrequency of permanent ankylosis after a 
simple fracture, when the case has been properly treated, whether by the 
flexed or straight position ; while, if the limb is flexed, a maiming, as a 
result of the great length of the intermediate ligament, is quite as likely 
to occur. Yet if, in any case, from the great severity and complications 
of the injury, especially in certain examples of compound and com- 
minuted fracture, it were to be reasonably anticipated that permanent 
bony ankylosis must result, or even where the probabilities were strongly 
that way, the surgeon might be justified in selecting for the limb, at once, 
the position of semiflexion ; or he might leave the arm without a splint, 
and at liberty to draw up spontaneously and gradually to this position, 
as it is always very prone to do. 

In favor of moderate, but not complete extension, it is claimed that it 
is less fatiguing than the latter position, while it accomplishes a more 
exact apposition of the fragments, if they happen to be brought actually 
into contact. I am unable, however, to understand how the apposition 
can be rendered less exact by complete extension, unless by this is meant 
a degree of extension beyond that which is natural, and which, I am 
well aware, is permitted to the elbow-joint when this posterior brace is 
broken off. It would certainly derange the fragments to place the arm 
in this extreme condition of extension— that is, in a condition of exten- 
sion approaching dorsal flexion, which is beyond what is natural. In- 
deed, perhaps, we may admit that, in order to perfect apposition, the 



FRACTURES OF THE OLECRANON PROCESS. 307 

extension ought to be less by one or two degrees than what is natural, 
sufficient to compensate for the trifling amount of effusion which may be 
presumed to have occurred in the olecranon fossa, and which would pre- 
vent the process from sinking again fairly into its fossa. As to its being 
less fatiguing, it is well known to those accustomed to treat fractures of 
the thigh by permanent extension that the muscles rapidly acquire a 
tolerance, which soon dissipates all feeling of fatigue, and that, after a 
few hours, or days at most, the patients express themselves as being more 
comfortable in this position than in the flexed. 

Finally, the advocates of complete, natural extension claim that in 
this position alone is the triceps most perfectly relaxed, and consequently 
the most important indication, namely, the descent of the olecranon, 
most fully accomplished. In this opinion we also concur; and regarding 
all other considerations, in the early days of the treatment, as secondary 
to this one, we unhesitatingly declare our preference for what has been 
called the " position of complete extension," as opposed to flexion, semi- 
flexion, or extreme extension. 

It only remains for us to determine by what means the limb can be 
best maintained in the extended position, and the olecranon process most 
easily and effectually secured in place. 

For this purpose a variety of ingenious plans have been devised, such as the 
compress and " figure-of-8 " bandage of Duverney, without splints; or a similar 
bandage employed by Desault, with the addition of a long splint in front; the 
circular and transverse bandages of Sir Astley Cooper, with lateral tapes to 
draw them together, to which also a splint was added ; and many other modes 
not varying essentially from those already described, but nearly all of which are 
liable to one serious objection, namely, that if they are applied with sufficient 
firmness to hold upon the fragment, and Boyer says they "ought to be drawn 
very tight," they ligate the limb so completely as to interrupt its circulation, 
and expose the limb greatly to the hazards of swelling, ulceration, and even 
gangrene. How else is it possible to make the bandage effective upon a small 
fragment of bone, scarcely larger than the tendon which envelops its upper end, 

Fig. 171. 




Sir Astley Cooper's method. 

and with no salient points against which the compress or the roller can make 
advantageous pressure? If, then, these accidents — swelling, ulceration, and 
gangrene^— are not of frequent occurrence, it is only because the bandage has 
not been generally applied " very tight," and while it has done no harm, it has 
as plainly done no good. 

The dangers may be easily avoided, without relaxing the security 
afforded by the compress and bandage, by a method which is very sim- 
ple, and the value of which I have already sufficiently determined by my 
own practice. The surgeon will prepare, extemporaneously always, for 
no single pattern will fit two arms, a splint, from a piece of thin, light 



308 FRACTURES OF THE ULNA. 

board. This must be long enough to reach from near the wrist-joint to 
within three or four inches of the shoulder, and of a width nearly or 
quite equal to the widest part of the limb. Its width must be uniform 
throughout, except that, at a point corresponding to a point three inches, 
or thereabout, below the top of the olecranon process, there shall be a 
notch on each side, or a slight narrowing of the splint. One surface of 

Fig. 172. 



The author's method when the fragments are widely separated. 

the splint is now to be thickly padded with hair or cotton-batting, so as 
to fit all of the inequalities of the arm, forearm, and elbow, and the whole 
covered neatly with a piece of cotton-cloth, stitched together upon the 
back of the splint. Thus prepared, it is to be laid upon the palmar sur- 
face of the limb, and a roller is to be applied, commencing at the hand 
and covering the splint, by successive circular turns, until the notch is 
reached, from which point the roller is to pass upward and backward 
behind the olecranon process and down again to the same point on the 
opposite side of the splint ; after making a second oblique turn above the 
olecranon, to render it more secure, the roller may begin gradually to 
descend, each turn being less oblique, and passing through the same 
notch, until the whole of the back of the elbow-joint is covered. This 
completes the adjustment of the fragments, and it only remains to carry 
the roller again upward, by circular turns, until the whole arm is covered 
as high as the top of the splint. 

The advantage of this mode of dressing must be apparent. It leaves, on each 
side of the splint, a space upon which neither the splint nor bandage can make 
pressure, and the circulation of the limb is, therefore, unembarrassed, while it 
is equally effective in retaining the olecranon in place, and much less liable to 
become disarranged. 

Before the bandage is applied about the elbow-joint, the olecranon 
must be drawn down, as well as it can be, by pressure with the fingers, 
and a compress of folded linen, wetted to prevent its sliding, must be 
placed partly above and partly upon the process ; at the same time, 
also, care must be taken that the skin is not folded in between the 
fragments. 

When the fragments are not much, or at all separated, and conse- 
quently no such force is required to draw down the upper fragment, and 
when, from the nature of the injury, there is little cause to anticipate 



FRACTURES OF THE OLECRANON PROCESS. 309 

much swelling, a splint may be employed, constructed like that recom- 
mended by Sir Astley Cooper, made of light wood, curved to fit the 
limb, or of gutta-percha, gum-shellac cloth, or sole-leather. This should 
be covered with a flannel or cotton sack, and then secured in place by a 
roller. The sack will enable the surgeon to stitch the roller to the 
splint, and he can thus employ effectively the oblique and figure-of-8 
turns about the elbow joint. Indeed, the latter method will prove ade- 
quate in most cases, while it is less cumbrous than that which I have 
first described as being required when the separation is very great, and 
the injuries unusually severe. 

The dressing ought, no doubt, to be applied immediately, since, if we 
wait until the swelling has subsided, it will be found much more difficult 
to straighten the arm completely than it would have been at first, and 
the olecranon process will be more drawn up and fixed in its abnormal 
position. Something will be gained by these means, adopted early, even 
if the bandage cannot be applied tightly : and moderate bandaging will 
not in any way interfere with the proper and successful treatment of the 
inflammation. We must always keep in mind, however, the fact that 
the fracture being usually the result of a direct blow, considerable inflam- 
mation and swelling around the joint are about to follow rapidly ; and 
on each successive day, or oftener if necessary, the bandages must be 
examined carefully, and promptly loosened whenever it seems to be nec- 
essary. For this purpose it is better not to unroll the bandages, but to 
cut them with a pair of scissors, along the face of the splint, cutting only 
a small portion at a time, and as they draw back, stitch them together 
again lightly : and thus proceed until the whole has been rendered suffi- 
ciently loose. 

As soon as the inflammation has subsided, and as early sometimes as 
the fifth or seventh day, the dressing ought to be removed completely ; 
and while the fingers of the surgeon sustain the process, the elbow ought 
to be gently and slightly flexed and extended two or three times. From 
this time forward, until the union is consummated, this practice should 
be continued daily, only increasing the flexion each time, as the inflam- 
mation and pain may permit. If it is thought best, at length, to change 
the angle of the arm, and to flex it more and more, it may be done easily 
by substituting a very thick sheet of gutta-percha for either of the other 
forms of dressing. 

DiefFenbach has several times, in old fractures of both the olecranon and 
patella, where the fragments were dragged far apart, divided the tendons, so as 
to be able to bring the two portions together, and, by friction of them one upon 
the other, has endeavored to excite such action as might end in the formation of 
a shorter and firmer bond of union. In some instances, it is said, considerable 
benefit was obtained, after all other means had failed ; in others, the result was 
negative. One example of an old ununited fracture of the olecranon is men- 
tioned, in which he divided the tendon of the triceps, secured the upper frag- 
ment in place, and every fourteen days rubbed it well against the lower one; in 
three months "the union was firm." 1 

Mr. Lister, in the case of a patient whose olecranon had been broken many 
months before, and not satisfactorily united, exposed, with antiseptic precau- 

1 DiefFenbach, American Journal of the Medical Sciences, vol. xxix. p. 47S: from Casper's 
Wochenschrift, Oct. 2. 1841. 



310 FRACTURES OF THE ULNA. 

tions, the fragments and brought them together with strong silver wire, thus 
securing a bony union without any accident. He has repeated this operation in 
an analogous case, with like success. 1 Rose, 2 MacCormac, 3 and Lesser 4 have 
each reported one example of success in the same class of cases. Neither the 
method of Dieffenbach nor that of Lister is without its hazards, and no doubt 
ought to be reserved for extreme cases. 

[The wiring of the fragments antiseptically is a very simple and safe opera- 
tion, and secures firm bony union. I have operated in several instances without 
an unfavorable symptom.] 

Plaster-of-Paris, or any other form of immovable dressing which excludes the 
surface of the limb from observation, and which is made sufficiently tight to hold 
permanently upon the upper fragment, exposes the patients to the dangers of 
swelling and gangrene. If not sufficiently tight to expose to these dangers, they 
serve no other purpose than to keep the limb straight. 

In 1850, Kigaud, 5 of Strasbourg, introduced two screws into the upper and 
lower fragments, respectively, and drew them together with a string. The screws 
remained in position two months, and the result was a "perfect cure." One 
might wish to know more precisely in what sense it was "perfect.'' 

In 1864, Busch applied a plaster-of-Paris splint, furnished with a fenestra at 
the posterior part of the elbow ; after which he made fast a metallic clamp, one 
point of which penetrated the upper fragment, and the two lower points were 
made to penetrate the plaster-of-Paris; by means of a screw the fragments were 
approximated. 6 Madelung has three times adopted the same method ; in one 
of which the method had to be abandoned on account of the "indocility" of the 
patient. Pingaud 7 reports, also, an example of success by this method. 

Lauenstein proposes to aspirate the joint where there is much interarticular 
effusion, in order to secure better apposition of the fragments. The fact that he 
has seen no serious results from this practice, will hardly justify the prudent 
surgeon in performing an operation of so much hazard and of so little probable 
utility. 

Separation of the Olecranon while in its Epiphyseal State. — Recently 
a gentleman called upon me with his son, aged seven years, who had an 
unreduced dislocation of the radius and ulna backward of nine weeks' 
standing. While reducing this dislocation, it being necessary to flex the 
arm forcibly, the epiphysis constituting the olecranon process gave way, 
and became separated from one-half to three-quarters of an inch. This 
is the only example of separation of this epiphysis which has come to 
my knowledge. I have, however, twice since broken the olecranon in 
attempts to reduce old dislocations of the radius and ulna backward, and 
I have not regretted the occurrence, since it enabled me to reduce the 
dislocations without cutting the triceps. 

[Eames reports a case of fracture of the olecranon in a child four years of age, 
which was doubtless an epiphyseal separation. 8 ] 

§ 2. Coronoid Process of the Ulna. 

Dissections have established the existence of this fracture in the living 
subject. The fact, however, that the number of authentic observations 

1 Lister, The Lancet, June 4, 1881, p. 914. 

2 Rose, The Lancet, 1880, vol. 1. p. 835. 

3 MacCormac, The Lancet, June 4, 1881, p. 913. 

i Lesser, Quentin, Bruch. des Olek., Inaug. Diss., Bonn, 1881. 

5 Rigaud, Rev. Med. Chir., 1850. 

6 Busch, Poiusot, op. cit. p. 397. 

» Pingaud, Diet. Encyc, Art. Coude, p. 639 (1878). 
8 Brit. Med. Journ., July, 1887. 



CORONOID PROCESS OF THE ULNA. 311 

is very small, seems to imply that the accident is infrequent, and espe- 
cially as a simple fracture, unassociated with other fractures. 

Malgaigne thought that it was more frequent than the small number of re- 
ported examples would lead us to suppose; and especially because he had noticed 
how often the summit of the process is broken off when dislocation of the radius 
and ulna backward is produced on the cadaver. In three or four cases also of 
dislocations of these bones backward and inward which had come under his 
notice, he was unable to feel this process, and he, therefore, thought it probable 
that it was broken off. Other surgeons have thought also that it was not an 
infrequent accident in connection with a dislocation. Fergusson has, indeed, 
made the extraordinary statement that in dislocations of the radius and ulna 
backward "the coronoid process will probably be broken." 

In the two following cases, the existence of a fracture of the coronoid 
process was at first suspected by me, but I have now very little doubt 
that my diagnosis was incorrect. I shall relate them, however, as 
examples of those accidents which are likely to be mistaken for fracture 
of this process. 

A laboring man, aged about twenty-five years, had been seen and treated by 
another surgeon, for what was supposed to be a simple dislocation of the radius 
and ulna backward. The surgeon thought he had reduced the dislocation very 
soon after the accident. On the following day he found the dislocation repro- 
duced, and he requested me to see the patient with him. The arm was then 
much swollen, but the character of the dislocation was apparent. By moderate 
extension, applied while the arm was slightly flexed, and continued for a few 
seconds, reduction was again effected, the bones returning to their places with 
a distinct sensation ; but on releasing the arm the dislocation was immediately 
reproduced. These attempts to reduce and retain in place the dislocated bones 
were repeated several times during this day and on subsequent days, but to no 
purpose, and the patient was dismissed after about two weeks with the bones 
unreduced. The possibility of retaining the bones in place, and the existence 
of an occasional crepitus during the manipulation, inclined me to believe at the 
time that the dislocation was accompanied with a fracture of the coronoid 
process. 

Another similar case has since presented itself in a child nine years old, and 
in which the subsequent examinations not only demonstrated the non-existence 
of a fracture, but also rendered doubtful the justness of the conclusions which I 
had drawn in the case just related. This lad fell, November 4, 1855, and his 
parents immediately brought him to me ; but as he lived many miles from town, 
I did not see him until eighteen hours after the injury was received. I found 
the arm much swollen, slightly flexed, and pronated. Flexion and extension of 
the arm were very painful, the pain being referred chiefly to the front of the 
joint, near the situation of the coronoid process; and at this point also there 
was a discoloration of the size of a twenty-five cent piece. Flexing the forearm 
moderately upon the arm and making extension, the bones came readily into 

Fig. 173. 




Fracture of the coronoid process. 

place, but without sensation of any kind, either a snap or a crepitus. That the 
bones had now resumed their position, however, I made certain by a very care- 
ful examination with the hand and by measurement, yet they would not remain 
in place one moment when the extension was discontinued. The reduction was 
made several times, and constantly with the same result. We then applied a 



312 



FRACTURES OF THE ULNA. 



Fig. 



right-angled splint to the arm, having first reduced the bones, and thus were able 
to retain them in position. I believe that the coronoid process was broken, and 
so informed the surgeon, to whose care the boy returned. Five months after, he 
was brought again to me, and I then found that the radius and ulna had been 
kept in place ; the motions of the joint were perfect, and if the coronoid process 
had ever been broken it was now again in its natural position, and with every 
structure about it in a condition as complete as it was before the accident. 

Malgaigne mentions three reported examples, namely, one published by 
Combes Brassard, an Italian surgeon, in 1811, which Brassard saw only after a 
lapse of three months ; one seen by Pennock, and published in the Lancet in 
1828, the patient then being sixty years old, and the accident having occurred 
when he was a young man ; the third was seen by Sir Astley Cooper, several 
months after the accident. 

Dr. Physick once saw a fracture of the coronoid process. The symptoms 
resembled a luxation of the forearm backward, " except that when the reduc- 
tion was effected, the dislocation was repeated, and by careful examination 
crepitation was discovered. The forearm was kept flexed at a right angle with 
the humerus. The tendency of a brachialis internus to draw up the superior 
fragment was counteracted in some measure by the pressure of the roller above 
the elbow. A perfect cure was readily obtained.'' 1 In 1830, Dr. William M. 
Fahnestock reported a case occurring in a boy, who, having fallen from a hay- 
mow, received the whole weight of his body " on the back part 
of the palm of the left hand," while the arm was extended for- 
ward. It seemed to be a dislocacation of the forearm backward, 
but when reduced it was again immediately displaced, with an 
evident crepitus. The arm was secured in the angular splint of 
Dr. Physick, and " recovered very speedily." 2 

Dr. Duer, 3 of Philadelphia, has reported a case which occurred 
in a boy six years old, and in which he felt and moved the frag- 
ment with his fingers. It was complicated with a dislocation, 
which remained unreduced. 

Mr. Liston saw a case in which the injury arose in conse- 
quence of the patient, a boy of eight years, having hung for a 
long time from the top of a wall by one hand, afraid to drop 
down." 4 The explanation of the accident in the case of the 
boy, given by Liston, implies two anatomical errors : first, 
that the coronoid process is an epiphysis during childhood; 
and second, that the brachialis anticus is inserted upon its 
summit. The coronoid process is never an epiphysis, but is 
formed from a common point of ossification with the shaft; 
the olecranon process and the lower extremity of the ulna 
having also separate points of ossification; the olecranon be- 
coming united to the shaft at the sixteenth year, and the lower 
epiphysis at the twentieth. Moreover, the brachialis anticus 
has its insertion at the base of the process and partly upon the 
body of the ulna, but in no part upon its summit ; indeed, the 
process seems rather to be intended as a pulley over which the 
brachialis anticus may play ; resembling also somewhat, in its 
function, the patella; serving to protect the joint and perhaps 
the muscle itself from becoming compressed in the motions of 
the joint. Certainly it could never have been broken by the 
action of this muscle, and the case mentioned by Mr. Liston 
must find some other explanation. It may have been a rupture 
of the brachialis anticus itself, or of the biceps, or possibly a 
forward luxation of the head of the radius. Either of these suppostions is 
more rational than the statement made by Mr. Liston, because either one of 
them is possible, while his supposition is impossible. 

The first two of the above enumerated (Brassard's and Pehnock's) were not 

1 Dorsey, Elements of Surgery, vol. i. p. 152. Philadelphia, 1813. 

2 Fahnestock, Amer. Journ. Med. Sci., vol. vi. p. 267. 

3 Duer, Amer. Journ. Med. Sci., Oct. 1863, p. 390. 
* Liston, Practical Surgery, p. 55. 



^ 



r 

Ulna,with epi- 
physis. (From 
Gray.) 



CORONOID PROCESS OF THE ULNA. 313 

satisfactory to Malgaigne ; the third is spoken of cautiously by Sir Astley Cooper, 
as if it needed, in addition to his own great name, the indorsement of the 
" London council." Dorsey reports his case upon hearsay, and the result is 
quite too satisfactory to give it much claim to credibility. Fahnestock's case is, 
to my mind, far from being fully proven. Liston's case was simply impossible. 
Duer's case could have been better verified at a later period. 

Ulrichs, 1 Battams, 2 Laugier, 3 Lorinzer, 4 Zeis, 5 Lotzbeck, 6 Comoy, 7 Gripat, 8 have 
also reported clinical examples not verified by dissection. 9 

In the case described by Laugier, a boy, set. 12, had fallen upon the right 
hand, the forearm being slightly flexed. He was admitted to the hospital with 
a dislocation of the radius and ulna backward. The dislocation was easily 
reduced, and the motions of the joint were completely restored. The swelling 
having subsided after ten or twelve days, a small, very hard, circumscribed 
and slightly movable tumor was observed a little below the end of the elbow, 
which interfered with flexion. 

Having described the case, of which I have only given a summary, Poinsot 
relates what he regarded as a similar case sent to him by his colleague, M. Gau- 
tier. A man, twenty days before, had fallen upon his hand. Gautier found a 
dislocation, which he reduced easily, and the motions of the joint were com- 
pletely restored. When seen by Poinsot there existed a hard circumscribed 
tumor, which seemed united to the tendon of the brachials anticus. The limb 
could not be flexed well. Upon careful examination, Poinsot, who at first thought 
it might be a fracture of the coronoid process, decided that it was " an indura- 
tion such as results from certain contusions; and that opinion seems now to be 
confirmed by the researches of M. Charvot, on the transformation of sanguino- 
lent deposits at the bend of the elbow. I believe that Laugier's case should 
receive the same explanation." 

Poinsot refers also to the two supposed cases reported by Lorinzer and Comoy, 
respectively, both accompanied with a dislocation backward. In the first case 
there was marked bony crepitus in the region of the coronoid process, but 
Lorinzer was compelled to recognize the fact that no swelling existed in the 
supposed seat of fracture. In the second case, a fine and dry crepitus could be 
felt at the bend of the arm. Professor Richet, in whose wards the patient was, 
recognized a fracture, but could not fix its exact location. 

The three cases met with by Lotzbeck presented, says Poinsot, '' a most complete 
similarity with each other. In the three instances, there was felt at the bend 
of the elbow a small tumor, hard and circumscribed, movable laterally, and 
giving rise to crepitation when moved. The displacement (twice both bones, 
and once the ulna only were dislocated) was easily reduced, but would be re- 
produced immediately. In the three cases the cure was accomplished and the 
movements of flexion were regained pretty promptly and with almost their 
normal freedom.'' 

Of the clinical case reported by Ulrichs, the same writer remarks : " A young 
boy fell upon his left side while helping to carry a beam whose weight was rest- 
ing on his left forearm, which was bent at a right angle. He experienced a 
violent pain and could neither flex nor extend the forearm. The surgeon who 
was called felt a pretty obscure crepitus in the region of the bend of the elbow; 
but there being no displacement of the bony prominences, the diagnosis of frac- 
ture of the coronoid process was made by exclusion." 

"M. J. Scott Battams, of Royal Free Hospital," says Poinsot, "thought he 
had to deal with a fracture of the coronoid process in the case of a man who, 

1 Ulrichs, Deuts. Zeits. fur Chir., t, 10, Nov. 1878. 

2 Battams, The Lancet, 1878, vol. ii. p. 607. 

3 Laugier, Bullet Chir., 1840. 

4 Lorinzer, Zeits. der K. K. Ges. cler Ac. fur Wein, vii. Jahr., Heft 7. 

5 Zeis, Schmidt's Jahr. fur 1866, p 134. 

6 Lotzbeck, Die Frak. Pr. Cor., Miiuchen, 1865. 

7 Comoy, Frac. de l'Apoph. Cor., etc., These Paris, 1881. 

8 Gripat, Bull. Soc. Anat., 1872. 

9 When speaking of fractures of the head of the radius I have said that Dr. Hodges had 
three times found the coronoid process broken in that connection. I ought to have said he 
had found in the reported dissections. To these I shall hereafter refer. 



314 FKACTURES OF THE ULNA.. 

slipping on a sidewalk, had his elbow caught between his hip and the pavement. 
At first it was difficult to determine the nature of the lesion ; the patient could, 
with pain it is true, extend and flex the forearm a little beyond a right angle. 
Supination and pronation were performed slowly, but well ; the bony promi- 
nences of the elbow had kept their normal relations, and the head of the radius 
was in its ordinary position. Up to that time the patient had supported the 
wounded arm with the other hand ; suddenly he allowed it to drop, and at once 
the ulna was dislocated backward, the radius remaining in place. This disloca- 
tion was reduced easily, but to be reproduced with the same facility. The limb 
was placed on an elbow-splint, which was allowed to remain for three weeks. 
At that time, there existed a small indurated growth on a level with the coronoid 
process, at the point where in the beginning there was a bloody effusion. The move- 
ments, at first impeded, were soon completely regained." 

The fact, therefore, that so few cases have ever been reported, and that 
most of these are far from having been clearly made out, remains pre- 
sumptive evidence that the actual cases are exceedingly rare ; but if to 
this we add such evidence as is furnished by actual dissections, and by 
examinations of the pathological cabinets of the world, we think the testi- 
mony is almost conclusive. 

In 1834, M. Berard 1 examined the arm of a man who had been killed by a fall 
from a second story. The forearm was dislocated backward. In attempts at 
reduction and redislocation, there was observed, under moderate pressure, a 
slight crepitation. There was found a fracture of the coronoid process, of the 
anterior third of the head, including a portion of the neck. Sir Astley Cooper 2 
says that a person was brought to the dissecting-room at St. Thomas's Hospital, 
who had been the subject of this accident. "The coronoid process, which had 
been broken off" within the joint, had united by a ligament only, so as to move 
readily upon the ulna, and thus alter the sigmoid cavity of the ulna so much as 
to allow in extension that bone to glide backward upon the condyles of the 
humerus." Mr. Bransby Cooper adds, in a note, that the external condyle of 
the humerus was also broken and united by a ligament. Samuel Cooper 
describes, rather obscurely, a specimen contained in University College Museum, 
"in which the ulna is broken at the elbow, the posterior fragment being dis- 
placed backward by the action of the triceps ; the coronoid process is broken 
off; the upper head of the radius is also dislocated from the lesser sigmoid 
cavity of the ulna, and drawn upward by the action of the biceps. In this 
complicated accident the ulna is broken in two places." Velpeau has also estab- 
lished by two autopsies the existence of a fracture of the coronoid apophysis. 

Lotzbeck 3 has seen, as he thinks, an ancient fracture of this process in the 
cadaver, the line of fracture passing beneath the lesser sigmoid cavity and into 
the greater sigmoid cavity. The condyle was broken also, and was reunited by 
fibrous tissue and cartilage. The coronoid was united by bone, and loaded with 
osteophytes. 

Ulrichs 4 found, in a cadaver, a fissure of the summit of the coronoid process, 
caused by torsion or twisting of the forearm, without any other lesion of the 
bone. In a cadaver seen by Gripat, the coronoid process was fractured at its 
base, and the radius and ulna were dislocated backward and upward. 

Allandale 5 also, having performed resection for an ancient dislocation, found 
this process fractured, and a bony callus had united the ulna to the humerus. 

Gurlt 6 has described a specimen, contained in the museum at Braunschweig, 
illustrating a fracture of the extremity of the coronoid process. A small frag- 
ment was also broken from the ulnar side of the olecranon. Both fragments 
have united by bone. 

1 Berard, Die. de Med., Art. Coude. 

2 Sir A. Cooper, Dislocations and Fractures, p. 411. 

3 Lotzbeck, loc. cit. 

4 Ulrichs, loc. cit. 5 Allandale, Med. Times and Gaz., May 25, 1875. 
6 Gurlt, Von den Knocken., 1862, vol. i. p. 41. 




CORONOID PROCESS OF THE ULNA. 315 

Says Mr. Flower, Conservator of the Museum of the Royal College of Surgeons, 
u The cases that have been reported in which it has been observed in the living 
subject are exceedingly unsatisfactory." . . . "I have been able to meet 
with but three or four specimens, and recorded post-mortem 
examinations of this injury '' (alluding, I presume, to clinical 
cases). " One of the former is in the museum of Guy's Hos- 
pital. Another case is that of a man killed by a fall from 
the roof of St. George's Hospital ; in whom the coronoid pro- 
cesses were found to be fractured, and the two bones of the 
forearm dislocated backward on both sides." 1 The first of 
the specimens (Guy's Hospital) has been described by Mr. 
Bryant, 2 as having occurred in a woman seventy years old, 
and as having been caused by a fall upon the elbow. In 
addition to a fracture of the coronoid near its extremity, 
there was a comminuted fracture of the anterior third of the 
head of the radius. (Fig. 175.) It will be observed that in 
several of the cases verified by dissection, the fracture of the 
coronoid process was accompanied with other fractures in the Bryant s case 
vicinity of the joint; a circumstance which would not usu- fracture of the cor- 
ally permit them to be studied or classified as simple frac- onoid process and 
tures. Perhaps, however, we ought to consider, from the head of the radius, 
frequency of its concurrence, a longitudinal fracture of the 
head of the radius as a natural complication of the fracture now under considera- 
tion, when it is caused by a dislocation of the radius and ulna backward. 

Causes. — Judging from the clinical cases alone, it would seem that 
the most frequent cause of this accident is a fall upon the outstretched 
hand, and generally upon the palm of the hand ; the force of the blow 
being received upon the lower end of the radius, and, through its numer- 
ous muscles and ligamentous attachments, being indirectly conveyed to 
the ulna, producing a violent concussion of the coronoid process against 
the trochlea of the humerus, and resulting finally in a fracture of this 
process and a dislocation of both bones of the forearm backward. The 
examples verified by dissection, however, seem to have been produced by 
a variety of causes. 

The gentleman seen by Sir Astley had fallen upon his extended hand while 
in the act of running. Brassard's patient had fallen also upon his hand with 
his arm extended in front. The same was the fact in the cases seen by Lorinzer, 
Richet, and Lotzbeck; the latter of whom has recorded two cases due to this 
cause. Pennock's patient, a man of sixty years, had fallen upon the palm of 
his hand, and Fahnestock's fell upon the " back of the palm." In one of Lotz- 
beck's cases the fracture was supposed to be caused by extreme flexion of the 
forearm ; and in another case of supposed fracture, seen by Lotzbeck, it seemed 
to be the result of direct violence. While in a case seen by Ulrichs, a longitu- 
dinal fissure was caused by violent torsion or twisting of the forearm. In the 
case mentioned by Bryant, the patient fell upon her elbow. The fracture was 
compound and amputation was required. He remarks that in aged subjects this 
step may be demanded. 

Symptoms. — Partial or complete displacement of the ulna, or of the 
radius and ulna, backward, is accompanied with the usual signs of these 
luxations. In two of the examples mentioned by Malgaigne there w T as a 
luxation of the forearm backward ; such was also the fact in the case 
seen by Fahnestock ; in Couper's case it was dislocated backward and 
outward, and in Sir Astley's case I infer that there w T as only a sub- 

1 Fknver, Holmes's Surgery, 2d Xew York ed., vol. ii. p. 790. 

2 Bryant, System of Surgery, 1st London ed., pp. 939, 941. 



316 FRACTUKES OF THE ULNA. 

luxation of the ulna backward. In a case seen by Gripat, verified by an 
autopsy, there was a dislocation of the ulna. In the cases of Lorinzer 
and Richet, both bones were dislocated backward, and in two of those 
seen by Lotzbeck. A feeble crepitus has sometimes been recognized ; 
and it is fair to presume that in some examples the fragment, carried 
forward by being driven against the trochlea, may be felt displaced and 
movable in the bend of the elbow. We must be careful, however, not 
to mistake a hard nodule following traumatisms in this region, and the 
frequent occurrence of which has been signalized by Charvot, for the 
coronoid process. If only the summit is broken off, the brachialis anticus 
could have no influence upon it ; but if it were broken fairly through the 
base, it might be displaced slightly in the direction of the action of this 
muscle. The symptoms, however, which have been regarded as most 
diagnostic, are the disposition to reluxation manifested in most of these 
examples when the extension has been discontinued. But it must not 
be forgotten that other conditions than a fracture of the coronoid process 
may cause a reluxation, such as a fracture of the internal condyle, of the 
trochlea, or a splitting of the condyles, or some other derangement of the 
articular surfaces, or of the ligaments or muscles concerned in the articu- 
lation. Possibly, where the force applied has been great, as in falls from 
a great height, the brachialis anticus may have been detached. 

Prognosis. — In the absence of other testimony, we may be allowed to 
express an opinion that when the fracture has taken place across the 
summit or above the insertion of the brachialis anticus, nothing but a 
ligamentous union can be regarded as possible, since the fragment can 
only derive nourishment from a few untorn fibres of the capsule and 
perhaps of the internal lateral ligaments ; and although it may not be 
displaced, it cannot have the advantage of impaction, upon which alone, 
I suspect, a fracture of the neck of the femur within the capsule must 
rely for a bony union, if it ever does so unite. If, however, the fracture 
has taken place at the base, and fortunately it has not become much dis- 
placed by the force of the concussion against the humerus, it does not 
seem to me improbable that under favorable circumstances a bony union 
might occur. It will be remembered that a good portion of the attach- 
ment of the brachialis anticus is still below the fracture, and the remain- 
ing fibres are not therefore very likely to displace the fragment, especially 
when the arm is sufficiently flexed, so as properly to relax this muscle. 
It will be of small importance, however, whether the union is bony or 
ligamentous, provided only there is not great displacement. 

In the case of Couper's patient, seen several months after the accident, the 
ulna projected backward while the arm was extended, but it was without much 
difficulty drawn forward and bent, and then the deformity disappeared. He 
thought that during extension the ulna slipped back behind the inner condyle 
of the humerus. Brassard's patient, seen after three months, retained the power 
of pronation and supination, with also extension, but flexion was impossible, the 
forearm being arrested in this direction by the small, slightly movable fragment 
of bone in front of the elbow-joint, and which was supposed to be the process 
itself. Pennock's old man, who had met with the accident in boyhood, had still 
the radius luxated forward and outward, and the olecranon more salient back- 
ward than in the sound arm. Extension and flexion were nearly but not quite 
complete. Fahnestock informs us that his patient "recovered completely," but 
whether without deformity or maiming we are not told. Couper says the bone 



SHAFT OF THE ULNA. 317 

was united in four weeks, and that only a slight deformity and a little stiffness 
remained. Physick's patient made a perfect recovery. " The same result," says 
Poinsot, "followed in Dr. Scott Battams's patient, in whom the difficulty in 
flexion and extension which existed at first, disappeared in a few weeks. In the 
case of Allandale, the dislocation had remained unreduced, but no mention is 
made of the kind of dressing employed at the beginning. In Lorinzer's case, 
the movements of the elbow remained limited, the patient could only flex the 
forearm to a right angle. On the contrary, Richet's patient showed no remain- 
ing trace of the accident when she left Hotel-Dieu at the end of fifty-two days. It 
has already been seen that in Lotzbeck's cases the result was no less favorable." 

Let us return to the examples verified by dissection and to the cabinet speci- 
mens. Rejecting the doubtful specimens belonging to Dr. Gibson, and that ot 
Lotzbeck, also those of " Hodges, 1 of Gripat, and of Ulrichs, where there was no 
opportunity to get a history of the fracture, as well as that of Allandale, where 
it is difficult to determine what part of the tumor surrounding the humerus and 
ulna is due to the consolidation of the fracture." (Poinsot.) In the specimen 
described by Gurlt, without a history, the fragment is united, in position, with 
exuberant callus on the anterior surface. And in one specimen referred to by 
Bryant, the coronoid process and a portion of the head of the radius having been 
broken, bony union has taken place without displacement of either. 

Samuel Cooper says that in the case of the University College specimen the 
radius remains dislocated forward and upward, and the olecranon is displaced 
backward, but he does not say whether the coronoid process has united, nor 
describe its position ; but Sir Astley informs us that in the example seen and 
dissected by him the process was united by ligament, which was sufficiently long 
and flexible to allow the fragment to move upward and downward in the motions 
of flexion and extension. 

Treatment. — Whatever view we take of the mechanism or pathology 
of this accident, the rational mode of treatment would seem to be to flex 
the arm at a right angle, and retain it a sufficient length of time in that 
position; not forgetting, however, the danger of ankylosis from long- 
continued confinement in one position. An angular splint may be use- 
ful in preventing motion at first, but I think it ought not to be continued 
beyond seven or ten days at the most. After this, a simple sling is all 
that is necessary, since from this period some motion must be given to 
the joint if we would take the proper precautions to prevent stiffness. 

Sir Astley Cooper thought the limb ought to be kept immovable three weeks, 
and Velpeau preferred four; but I cannot agree with them, believing that the 
question of the future mobility of the elbow-joint is vastly more important than 
the question of a bony or ligamentous union between the fragments. Couper 
says that he adopted in the treatment of the case reported by him, extreme 
flexion; but both Physick and Fahnestock placed the arm at right angles, and 
Sir Astley Cooper has recommended the same position. The latter position has 
always the advantage in case permanent ankylosis occurs, and the former cannot 
add much to the chance of complete replacement of the fragment. Bandages 
are only serviceable to retain the splint in place, and they may be thrown aside 
as soon as the splint is removed. 

§ 3. Shaft of the Ulna. 

Causes. — The shaft of the ulna, when it alone is the seat of fracture, 
is generally broken by a direct blow. 

1 The case of Hodges probably here referred to, and reported first in 1866, vol. 75, p. 383, 
of the Boston Medical and Surgical Journal, and subsequently in vol. 96, p. 65, of the same 
journal, was not, properly speaking, a fracture of the coronoid process, but a longitudinal 
fracture of the upper end of the ulna. 



318 



FRACTURES OF THE ULNA. 



I have never seen an exception to this rule; but Voison related a single ex- 
ception, in which it was said to have been broken by a fall upon the palm of 
the hand. Malgaigne thinks it most often broken when one seeks to ward off a 
blow with the arm ; but it has happened most often to me to see it broken by a 
fall upon the side of the arm. 

Point of Fracture, Direction of Displacement, etc. — In an analysis of 
thirty-six cases, I find the shaft has been broken eleven times in its upper 
third, fourteen times in its middle third, and ten times in its lower third. 
All portions seem, therefore, to be about equally liable to fracture. I 
think, also, the fractures have generally been oblique. 

Contrary to what has been observed by other writers, I have noticed 
that no law prevailed as to the direction in which the fragments have 
become displaced ; the broken ends being found directed forward, back- 
ward, inward, or outward, according to the direction of the blow which 
has occasioned the fracture; and this is in accordance with the general 
rule in other fractures occasioned by direct blows. No doubt, however, 
other things being equal, the tendency of the lower fragment would be 
toward the interosseous space, in consequence of the action of the pro- 
nator quadratus in this direction ; while the upper fragment, owing to 
its broad and firm articulation at the elbow-joint, can only be displaced 
forward or backward, at least to any great extent. 

Complications. — In no case of the shaft of a long bone have I found 
serious complications more frequent than in fractures of the shaft of the 
ulna. Four have been compound ; twelve complicated with 
Fig. 176. a forward, or forward and outward dislocation of the head 
of the radius ; one with a partial dislocation of the lower 
end of the radius backward ; and one with a dislocation of 
both radius and ulna backward at the elbow-joint. It will 
be seen, therefore, that eighteen, or nearly one-half of the 
whole number, have been seriously complicated. 

Symptoms. —Occasionally this fracture is found to exist 
without sensible displacement. In such cases the diag- 
nosis is sometimes difficult, and can only be determined by 
the crepitus and mobility. If, however, the ulna is firmly 
seized above and below the point which has suffered con- 
tusion, and pressed in opposite directions, these signs will 
generally be sufficiently manifest, and will render the diag- 
nosis certain. But in cases where there is considerable 
displacement, the inner margin of the bone is so super- 
ficial as to enable us to detect its deviations with the eye 
alone, or, when swelling has already occurred, by the fin- 
gers carried firmly and slowly along this margin. If the 
head of the radius is dislocated also, the displacement of 
the broken ends of the ulna must always be considerable, 
and the consequent deformity palpable. 
Fracture of Prognosis. — In simple fractures the prognosis is gener- 
the shaft of the ally favorable, since no overlapping can occur, and the 
ulna. lateral displacements are not usually sufficient to produce 

a marked deformity, or to interfere materially with the 
functions of the arm; yet it is not unfrequent to find the fragments 
inclining slightly forward or backward, inward or outward. If the frag- 



SHAFT OF THE ULNA. 319 

ments fall toward the radius, I have noticed in three or four instances a 
slight projection of the lower end or styloid process of the ulna to the 
ulnar side ; but not interfering in any degree with the motions of the 
wrist-joint. 

I have seen a dislocation of the head of the radius left unreduced nine times 
after a fracture of the ulna/and in each example the forearm was shortened. A 
boy, set. seventeen years, was struck by a locomotive and severely injured in 
various parts of his body. I saw him, with two very intelligent country prac- 
titioners, a few hours after the accident. The whole left arm was then greatly 
swollen. Crepitus was distinct, and we easily recognized the fracture of the 
ulna about three inches below its upper end, with which an open wound was in 
direct communication. We suspected, also, a dislocation of the head of the 
radius forward, but as we could not make ourselves certain, and finding that 
the arm was in such a condition as to preclude any further manipulation without 
greatly diminishing the chance of saving the limb, we made no attempt at reduc- 
tion, but laid the arm upon a pillow and directed cool water lotions. At no sub- 
sequent period, in the opinion of the medical gentleman who was left in charge, 
did a favorable opportunity occur to reduce the radius ; and at the end of two 
months I found the ulna united, with the fragments bent forward and outward 
toward the radius, while the head of the radius lay in front of the humerus. The 
forearm was shortened three-quarters of an inch. He could flex his arm freely 
to a right angle and a little beyond; and he could straighten it perfectly. 
Hand slightly pronated, with partial loss of supination. Whole arm nearly as 
strong and as useful as before the accident. 

Three times I have noticed after the lapse of several years that the 
forearm could not be perfectly supinated ; but pronation was never per- 
manently impaired. I think, also, that the motions of flexion and exten- 
sion have always, except where the radius has remained dislocated, been 
completely restored soon after the splints were removed ; and even in 
these latter cases it is only extreme flexion which has been hindered. 
I have occasionally met with examples in which this bone has failed to 
unite, and Muhlenberg, in his tables, records sixteen cases. 

Treatment. — In simple fracture we must look carefully to the lateral 
deviation of the fragments ; and if they are found to be salient forward 
or backward, pressure made directly upon or near their extremities 
restores them to place ; but it often requires considerable force to accom- 
plish this. 

A gentleman fell and broke the right ulna near its middle. He came imme- 
diately to me, and I found the fragments displaced backward. Pressing strongly 
with my fingers they sprung forward with a distinct crepitus, and I thought 
they were now in exact line. A broad and well-padded splint was applied to 
the forearm, and I took especial pains with compresses nicely adjusted from day 
to day, to keep everything in place. The arm was placed in a sling. Eight 
months after the accident this gentleman died of cholera, and I was permitted 
to dissect the arm. I found the fragments well united, but with a very palpa- 
ble projection of the fragments backward, in the direction in which they were 
at first. 

If the displacement is in the direction of the radius, it is more difficult 
to overcome, but its necessity is much more urgent, since, if the frag- 
ments fall completely against the radius, a bony union may take place, 
occasioning a complete loss of the power of pronation and of supination. 
While moderate extension is being made, and the hand is well supinated, 
the fingers of the surgeon should be pressed firmly, and in spite some- 



320 FRACTURES OF THE ULNA. 

times of the complaints of the patient, between the radius and ulna, and 
the fragments of the broken ulna fairly pushed out from the radius. The 
forearm may now be laid in the usual position against the front of the 
chest, midway between supination and pronation, and the same splints 
applied and in the manner which we shall hereafter describe for fractures 
of the shaft of both bones. 

We ought, however, especially to bear in mind the danger of pushing 
the fragments toward the radius, by allowing the sling or the bandage 
to rest against the middle of the ulnar side of the bone. To prevent 
this the sling ought to support the arm by passing only under the hand 
and wrist, or the forearm may be laid in a firm gutter, which will, touch 
the forearm only at the elbow and wrist, or it may be laid upon its back, 
as suggested and practised by Scott, and also by Fleury, the latter of 
whom, according to Malgaigne, had a case which had been treated in the 
position of semi-pronation, and which remained not only displaced, but 
refused to unite ; but when the arm was supinated, the fragments came 
at once into contact, and bony union speedily took place. This position 
may be adopted whenever it is found to be practicable ; but the position 
of semi-pronation is generally much more comfortable to the patient, at 
least when the forearm is laid across the chest, and I have found very 
few patients who would submit to a position of complete supination. 

In fractures accompanied with dislocation of the head of the radius for- 
ward and backward, nothing should prevent the immediate reduction of 
the dislocation but a demonstration of its impossibility, or a condition of 
the limb which would render manipulation hazardous It can be reduced, 
generally, by pushing forcibly upon the head of the bone in the direction 
of the socket, while the arm is moderately flexed so as to relax the biceps, 
and while extension is being made at the forearm by an assistant. In 
making the counter-extension, care should be taken to seize the lower 
end of the humerus by the condyles, rather than by its anterior aspect, 
by which precaution we shall avoid pressing upon and rendering tense 
the tendon of the biceps. 

A lad, set. nine years, fell from his bed, breaking the ulna and dislocating the 
head of the radius. Dr. Austin Flint was called on the following morning, and 
at his request I was invited to see the patient with him. We found the ulna 
broken obliquely near its middle, and the head of the radius dislocated forward. 
While Dr. Flint seized the elbow in front of the condyles, I made extension from 
the hand, the forearm being slightly flexed upon the arm, and at the same mo- 
ment I pushed forcibly the head of the radius back to its socket. The reduc- 
tion was accomplished easily aud completely. We then dressed the arm with 
an angular splint, constructed with a joint opposite the elbow. This was laid 
upon the palmar surface, and the whole was nicely padded, especially in front 
of the head of the radius. In two weeks pasteboard was substituted for the 
angular splint. At the end of six weeks I was permitted to examine the arm, 
and found the head of the radius perfectly in place, but the points of fracture 
slightly salient. All of the motions of the arm were fully restored. 

C. C, set. nine years, fell upon his arm, breaking the ulna obliquely near its 
middle, and dislocating the head of the radius forward. Dr. J. P. White being 
called, requested me to visit the patient with him. We found one of the broken 
fragments protruding through the skin on the inside of the arm. With great 
ease, a«d by simply pressing with considerable force upon the head of the radius, 
it was made to slide into its socket. Five weeks after I found all of the motions 
of the forearm completely restored, except that he could not extend it perfectly. 



FRACTURES OF THE RADIUS AND ULNA 



321 



The head of the radius was also a little more prominent in front than in the 
opposite arm. Four or five years later, the projection of the head of the radius 
had disappeared, and the functions of the arm were perfect. 

In Dr. Muhlenberg's tables of delayed and non-union, resection was 
practised three times, but with no recorded cures. This is a result which 
might reasonably be expected ; while drilling was practised six times, 
with five successes. 

§ 4. Fracture of the Styloid Process of the Ulna. 

The occasional complication of a Colles's fracture with a fracture of 
the styloid process of the ulna has already been noticed. Much more 
rarely this process is broken alone, as a result of direct violence. I am 
unable to speak of the symptoms or treatment of this accident farther 
than to say, that it must be easily recognized by its mobility, and prob- 
ably by the presence of crepitus ; and that its treatment demands immo- 
bilization, while the wrist is maintained in a straight position, or in a 
position slightly inclined toward the ulna. At least a fibrous union 
ought thus to be easily obtained. 



CHAPTEE XXIV. 

FRACTURES OF THE RADIUS AND ULNA. 

Causes. — In a majority of the examples of this fracture seen by me, 
which have been of such a character as to warrant an attempt to save 
the limb, the accident has been occasioned by a fall upon the palm of the 
hand while the arm was extended in front of the body. Yet this cause 
is not so constant as in fractures of the radius alone, since a considerable 
number have been occasioned by direct blows ; and if we were to add to 
this estimate all of those bad compound fractures which have demanded 
immediate amputation, the proportion of fractures occasioned by direct 
and indirect blows might be found to be pretty nearly balanced. 

Fig. 177. 




Fracture in the middle third. 



Point of Fracture, Character, Direction of Displacement, etc. — In a 

record of seventy-two fractures of both bones, not including gunshot 
fractures, or those demanding immediate amputation, I have found six 
broken in the upper third, thirty-one in the middle third, and thirty-five 

21 



322 



FRACTURES OF THE RADIUS AND ULNA. 



in the lower third. In one case the radius was broken three-quarters of 
an inch above its lower end, and the ulna about one inch below the coro- 
noid process. Four of the fractures belonging to the lower third were 
probably epiphyseal separations. Fifty-eight were simple, eight com- 
pound, one was comminuted, three both compound and comminuted, one 
complicated with a fracture of the humerus, and one with a partial luxa- 
tion of the lower end of the radius. With three exceptions, all of these 
more serious accidents were arranged among fractures of the lower third, 
and generally the bones had been broken near the wrist. 

Prognosis. — Generally these bones unite in from twenty to thirty days ; 
but I have seen the union occasionally delayed considerably beyond this 
time, and this delay has occurred especially in the case of the radius. 



Fig. i; 



Fig. 179. 



Fig. 180. 



Fig. 181. 





Joint between bones 
at point of fracture. 



Angular displacement 
of both bones. 



Fracture in the 
lower third. 



Union with slight 
lateral displace- 
ment. 



Thus, in three cases of compound and comminuted fracture, the ulna 
united within four or five weeks, while the radius did not unite until the 
ninth or tenth week. Twice in simple fractures the ulna has united in 
the usual time, but the radius not until the sixteenth week. Once the 
ulna has united promptly and the radius remained ununited at the end 
of two years, at which time I practised resection of the broken ends. 
On the other hand, I have once seen the union delayed four months 
in the case of the ulna, when the radius had united in the usual time ; 
and in one example of compound fracture both bones refused to unite 
until after the fifth month. Muhlenberg has recorded thirty-seven cases 
of delayed and non-union of both bones, out of a total of six hundred 
and fifty- six similar examples in all the long bones. 



FRACTUKES OF THE RADIUS AND ULNA. 323 

A majority of the whole number seen by me have united without any 
appreciable deformity, and fifteen are known to have left some marked 
defect, while two have resulted finally in the loss of the arm itself. 
I have seen the fragments deviate slightly in almost every direction, but 
most often it has been noticed that the deviation was to the radial or 
ulnar side. Thus, in three examples, two of which had been compound 
fractures, the bones have united in such a position as that from the point 
of fracture downward the forearm has been deflected to the ulnar side, 
and a marked projection has been left at the seat of fracture on the radial 
side ; while in two examples, both of which were simple fractures, exactly 
the opposite condition has obtained, the lower part of the forearm being 
deflected to the radial side. 

In most cases the hand has been left with some tendency to pronation ; 
in many instances this tendency was very slight and scarcely appreciable, 
but in others it has been quite marked, so that the patients have been 
wholly unable to supine the forearm except by a motion of the humerus 
in its socket. 

From what has been said, it must be seen that the prognosis in these 
accidents takes the widest range ; for while a larger proportion than in 
the case of almost any other of the long bones, unite without any appre- 
ciable deformity, a considerable number delay to unite, or do not unite 
at all, and some, even where the fracture is most simple, result in the 
complete loss of the limb. I am not now speaking of those more severe 
accidents in which the limb is at once condemned to amputation, and 
which, in the case of the arm, are numerous ; but, as I have already 
mentioned, our observations here apply only to cases which came under 
treatment with a view especially to the fracture. I shall state the facts 
more fully, and then perhaps we shall think it proper to inquire why, 
when, as a rule, the treatment is found to be so simple and successful, 
and pretty often, indeed, it results so disastrously. I have brought to- 
gether also no less than six cases of sloughing of the arm, after fracture 
of the radius, and one of sloughing from tight bandaging, where the 
radius was supposed to be broken, although the dissection proves that it 
was not. To these I shall now add eight examples of sloughing after 
fracture of both radius and ulna. 

J. M., set. 9, fell from a ladder, about thirty feet to the ground, breaking 
the right radius and ulna in their middle thirds. A surgeon was in attendance 
about four or five hours after the accident occurred. He then reduced the frac- 
tures and applied two broad splints, one on the palmar and one on the dorsal 
surface of the forearm. Whether a roller was first applied to the arm or not, I 
am unable to say. The splints were secured in place by a roller and the arm 
laid in a sling. On the fifth day the surgeon removed the bandages and found 
the arm gangrenous ; the arm finally fell off at the shoulder-joint, after which 
he made a good recovery. 

A child, two years old, had fallen from a chair upon the floor, a distance of 
about two feet. A German physician being called, found, as he believed, a frac- 
ture of both bones of the left arm. The fracture was near the middle. He 
immediately applied a roller from the fingers to the elbow, and over these three 
narrow splints made of the wood of a cigar-box. One of these was laid upon 
the palmar, one upon the dorsal, and one upon the radial side of the forearm, 
and the whole were bound together by another roller. From this time until the 
tenth day the child continued to play about on the floor. Ten days after the 
accident occurred the doctor noticed that the ulnar side of the little finger was 



324 FRACTURES OF THE RADIUS AND ULNA. 

blue. The bandages were immediately removed, and were never again applied 
tightly. Three days after, I saw the arm with the attending physician. The 
gangrene had continued to extend, involving now the whole of the little finger 
and most of the thumb. There were also gangrenous spots over the hand and 
forearm, extending to within one inch from the elbow-joint ; these spots were 
more numerous in front and on the back of the forearm, and seemed to corre- 
spond to the pressure of the splints. The hand was much swollen, and also the 
arm above the line of the gangrene. The sloughs had already commenced to be 
thrown off, and the gangrene was only extending in a few points. The child 
appeared well and rather playful, except when the arm was being dressed. I 
have since learned that the arm and a large portion of the hand were finally 
saved. A lad, aged nine years, was brought to the Dispensary, with a fracture 
of the radius and ulna. It was dressed by the visiting surgeon with splints and 
bandages. He did not return to the Dispensary as directed to do, and on the 
third or fourth day portions of the arm and hand were found to be gangrenous. 
I was consulted by the parents of D. C. on account of a serious distortion of 
the hand and forearm, caused by sloughing, splints and bandages having been 
applied by her surgeon for a supposed fracture ; but when examined by me, 
about ten weeks after the accident, there was no evidence that the bones had 
ever been broken. She complained to her surgeon that the bandages were too 
tight, but he thought otherwise, and they were not removed until the third day, 
when the gangrene had already occurred. The child was about five years 
old. A man, set. 20, suffered a simple fracture of the right radius and ulna 
March 14, 1874. On the same day it was dressed with a roller next to the 
skin and over this the splints. On the following day the fingers were black, but 
the same dressings were continued, and they were not removed completely 
until the next day. He was admitted to Bellevue on the 16th, and by courtesy 
of Dr. Gouley I was permitted to examine the arm on the 7th of April. He had 
then lost all of his fingers, except a portion of the thumb, and there were exten- 
sive sloughing and suppuration along the forearm. His death took place a 
few days later. 1 A. T., set. 50, fell upon her left hand, causing a compound 
fracture of the radius and ulna, about three inches above the wrist-joint. The 
surgeon dressed the arm with splints, applying the bandages "snugly.'' Two 
days later she was brought to one of my wards at Bellevue, with the back of the 
hand and most of the forearm in a state of gangrene, evidently caused by the 
bandages. Seven or eight days later she died before the house surgeon could 
reach her, from a secondary hemorrhage. In the following case there was 
probably no fracture; no doubt could be entertained as to the cause of the 
gangrene. A girl, set. 5, fell upon the palm of her hand. A surgeon saw her within 
one hour, put on two wooden splints, with cotton-batting laid loosely under- 
neath, securing them with a roller. Half an hour after it was dressed the fingers 
were blue, and the pain was so great that the surgeon was recalled. On his 
arrival he said it was not too tight. On the following day the condition was 
the same, but the surgeon refused to loosen the dressings. Two days later he 
removed the bandage, and found a slough extending nearly the whole length of 
the palmar surface of the forearm. Some months later I found the arm straight, 
but the hand much distorted by the cicatrix. 

I have now to relate a case in which sloughing and death occurred as the 
consequence of a tight bandage, the patient being under my own charge : J. B., 
set. 22, was admitted to Bellevue Hospital with a fracture of the left forearm, 
near its middle, caused by the kick of a horse on the day before. On the same day 
I dressed the fracture before the class of medical students in the hospital, using a 
palmar and dorsal board splint, covered and stuffed with cotton-batting, according 
to my usual method ; securing the splints with a roller, including the hand and 
forearm. The arm was then placed in a sling and he was sent io his ward. The 
following day being Sunday, I did not visit the hospital. On Monday I inquired 
for him, and learned that he was out walking in the yard. Tuesday I met him, 
returning from a walk in the yard, just as I was leaving the ward. He was 
apparently in perfect health, but, as I stopped him a moment to look at his arm, 
I saw that the hand was swollen and purple. The dressings were immediately 

1 New York Journ. Med., June, 1874. 



FRACTURES OF THE RADIUS AND ULNA. 325 

removed, and the patient placed in bed. There were upon the arm two spots 
looking like superficial sloughs. He was suffering no pain. The gangrene sub- 
sequently extended until it involved a large portion of the hand and forearm, 
and on the eighteenth day after the receipt of the injury he died. A careful and 
daily observation of the condition of the hand, and a prompt removal or loosening 
of the dressings when the hand first showed symptoms of arrest of circulation, 
would probably have prevented this disastrous result. The splints and bandages 
were removed the first time I saw him after the original dressings had been 
made, but this was too late ; some one should have seen the approaching cloud 
before it was ready to burst. 

How shall we explain the frequency of these accidents after fracture, espe- 
cially of the forearm ? Malgaigne, speaking of fractures of both bones of the 
forearm, remarks that " when the displacement is considerable, or more especially 
when the outward violence has been excessive, we frequently see follow a very 
intense inflammatory swelling, and there is no fracture which complicates itself 
so easily with gangrene under the pressure of apparatus." 1 

Says Nelaton : " If we make choice of the apparatus of J. L. Petit, it is neces- 
sary that it shall not be applied too tightly, for, as Professor Eoux has long 
since remarked, fractures of the forearm are those which furnish most of the 
examples of gangrene in consequence of an arrest of the circulation. This is 
easily understood, if we consider on the one hand the superficial position of the 
two principal arteries of the forearm, and on the other the disposition of the 
apparel, which must almost infallibly compress the arteries to a great extent." 2 

I do not think that this accident is due always to the negligence of 
the surgeon. It may be due many times to the carelessness of the parents 
or of the patient himself; as in the case of the boy who came under my 
own observation, and who lost his arm at the shoulder-joint. Sometimes 
also it may be due rather to the severity of the original injury, which, 
the experience of every surgeon will prove, is occasionally competent to 
the production of such bad results. A number of unfortunate circum- 
stances may have concurred, such as a severe injury, especially where 
the skin has remained unbroken and the efTused blood has had no oppor- 
tunity to escape — the broken bone may have rested against the trunk of 
a main artery, -causing an arrest of its circulation — the constitution may 
be impaired by previous illness, or it may be suffering under the shock 
of the injury ; yet that it may be and too often is the result of maltreat- 
ment on the part of the surgeon, is undeniable. It is proper, however, 
to discriminate between the responsibility which attaches to the surgeon 
as the true exponent of the state of his art, and that which attaches to 
the art itself as taught by the masters. The old surgeons applied first a 
roller to the hand and forearm, and over this their various splints. 

J. L. Petit thought he had made a valuable improvement upon this simple 
plan, by laying over the roller a compress and splint; the compress being in- 
tended to press between the bones, and to antagonize the action of the roller in 
drawing the fragments toward each other. Duverney believed that this object 
would be best accomplished by placing the pad against the skin, and under a 
circular compress; while Desault declared all of these modes inefficient, and 
announced a method which he regarded as accomplishing at once and com- 
pletely all of the indications; the sole peculiarity of which method consisted in 
placing graduated pads against the skin, and securing them in place by a roller. 
Boyer adopted the same method without any modifications, and Mr. Hind, in 

1 Malgaigne, Frac. et Disloc .,tom. i. p. 589. 

2 ISTelaton, Pathologie Chirurgicale, p. 735. 



326 FRACTUKES OF THE RADIUS AND ULNA. 

his illustrations of fractures, already referred to, has seen fit to recommend the 
same, at least in fractures of the radius. 

It is quite obvious that between these various methods there remains 
very little if anything to choose, the differences being too trifling and 
unessential to claim serious consideration. Each alike is inadequate to 
accomplish any amount of useful pressure between the fragments ; each 
alike is calculated to bind the bones one against the other, and each alike 
exposes to the danger of ligation and of gangrene of the hand and fore- 
arm. Says M. Dupuytren : " The practice of rolling the arm before the 
splints are applied, whether internal or external to the pads and com- 
presses, is eminently mischievous ; and instead of fulfilling, directly 
counteracts the indications which it is most important to keep in view. 
As to the width of the splints, surgeons are also very generally agreed, 
at the present day, that they ought to be wider than the arm, so as to 
prevent the roller or the tapes from resting against its sides. 

I do not intend to deny peremptorily, and without qualification, the 
value of the graduated compresses, which, as we have seen, are usually 
laid along the interosseous space to press the fragments asunder. It is 
necessary, however, to caution the surgeon against their injudicious use. 
And I suspect that to this portion of the dressing quite as much as to 
any other cause, are due those frightful accidents of which I have 
already spoken. The arteries are not only exposed, from their superficial 
position, to pressure from a compress, but, in addition to this, it will be 
noticed that the two principal arteries, the radial and the ulnar, are situ- 
ated upon a broad and flat surface of bone, along which this pressure 
must operate most advantageously. 

I have observed another fact in this connection : when this compress 
is extended low down on the palmar surface, within an inch or two of the 
wrist-joint, it soon becomes excessively painful, and sometimes even 
wholly insupportable, in consequence of the pressure made upon the 
median nerve ; and I find myself always obliged to exercise great care 
in the adaptation of the pads at this point. For this reason alone, I 
believe, in case of a fracture near the base of the radius, the lower frag- 
ment, if it were thrown toward the ulna, could not be retained in its 
place by graduated compresses. 

In short, finding that broad splints, properly covered and padded, 
answer very well to crowd the muscles into the interosseous space, so far 
as it is proper to do so, and believing that this mode is less painful and 
less dangerous, I never resort to graduated compresses, nor can I appre- 
ciate their necessity, or, indeed, their utility. 

Mayor, of Lausanne, says: "What signify graduated compresses placed 
between the bones of the forearm for the purpose of separating them from each 
other? These bones will not have that constant tendency to approach each 
other which has been supposed, provided, first, that they have been well reduced ; 
second, that for the purpose of maintaining them in position we do not make 
use of a preliminary circular bandage, whose action is an absurdity; and, in 
short, provided we make the retentive means act chiefly upon the palmar and 
dorsal surfaces of the forearm." 1 

1 Bandages et Appareils a Pansements, ou Nouveau Systeme Peligation Cbirurgicale, 
par M. Mathias Mayor, Chirurg. en Chef de l'Hopital de Lausanne, Switzerland. Paris 
ed., 1838, p. 345. 



FRACTUKES OF THE RADIUS AND ULNA. 327 

Surgeons have generally, after the splints have been applied, placed 
the forearm in a position of semi-pronation, or midway between supina- 
tion and pronation, so that the radius should be uppermost; it being 
assumed that in this position the two bones are most nearly parallel, and 
least inclined to displacement. 

Says Mr. South, in a note to Chelius : " In fractures of both bones the fore- 
arm is best laid supine ; " and Nelaton declares that in fractures of the radius 
and ulna at any point of their upper thirds it will be necessary to supine the 
arm, both in the reduction and during the subsequent treatment; but that in 
fractures of the inferior two-thirds we may place the limb in a condition of semi- 
pronation. It seems very probable, that both of these gentlemen have received 
their suggestions from Mr. Lonsdale, who, as we have already seen, has treated 
the question very much at length, and who has finally declared his decided 
preference for the supine position in the treatment of all fractures of the fore- 
arm. The advantages which he claims for this method are, more perfect coap- 
tation of the broken ends, less liability of the fragments to encroach upon the 
interosseous space, and consequently less danger of ankylosis between the bones 
and of non-union of the fragments, more complete restoration of the power of 
supination, and less tendency to lateral distortion, or of falling off to the ulnar 
or radial sides. 

My own cases, treated by the usual method, have shown that while 
supination is frequently impaired and sometimes entirely lost, pronation 
is rarely affected ; and that lateral displacements are much more common 
than displacements forward or backward. How this position, semi-pro- 
nation, may tend to the production of a permanent pronation, I have 
fully explained when speaking of fractures of the head of the radius ; 
and the influence of the same position, the forearm resting upon its 
ulnar margin in the sling, in the production of a lateral deviation, is also 
easily understood. If the arm rests upon the sling so that its weight 
bears more upon the point of fracture than upon the extremities of the 
bones, then the ulna, or both ulna and radius, will incline gradually to 
the radial side,' and the hand will fall off to the ulnar side ; or if the 
sling rests under the wrist or hand chiefly, the hand will ascend to the 
radial side, and the broken ends of the two bones will project to the 
ulnar side. If this plan be adopted, viz., laying the hand and forearm 
upon its back, instead of upon its ulnar margin, the elbow should remain 
at the side, the humerus falling perpendicularly from its socket; and the 
forearm should rest in the sling directed forward from the body. 

The following is the method usually employed by the author : Two 
thin, but firm, w r ooden splints are prepared, of uniform breadth, suffi- 
ciently wide that when the roller is 

applied it shall touch only lightly the Fig. 182. 

radial and ulnar margins of the fore- 
arm. The palmar splint should be 
long enough to extend from the bend 
of the elbow, the arm being flexed, to Palmar splint. 

the metacarpo-phalangeal articula- 
tions, the fingers being flexed. The dorsal splint should be a little 
shorter, or of a length to extend from the base of the olecranon process 
to the carpus. Both of these splints must be covered with cloth, and 
properly padded with cotton-batting ; taking care to leave but little of 




328 FRACTURES OF THE RADIUS AND ULNA. 

the cotton placed where it might press upon the radial and ulnar arteries 
and median nerve ; that is, at the front of the wrist. The splints, being 
carefully fitted, are applied while the forearm is held at a right angle 
with the arm, and in a position midway between pronation and supina- 
tion, one to the palmar and the other to the dorsal surface of the fore- 
arm, and secured with a roller. There must be no pressure against the 
humerus at the bend of the elbow ; and the fingers must be flexed easily 
over the lower end of the palmar splint. The dorsal splint should not 
extend beyond the lower end of the radius and ulna. It is understood, 
of course, that while the splints are being secured in place, extension 
and counter-extension are maintained for the purpose of securing coap- 
tation of the broken extremities as far as possible. The dressing being 
completed, the forearm is suspended in a sling. 

Finally, whatever may be the mode of dressing, let me repeat the 
injunction to examine the arm frequently. No surgeon can do justice to 
himself, or to his patient, who does not look at the arm at least once in 
twenty-four Lours during the first ten or fourteen days, and in some cases 
the patient ought to be seen twice daily. When the fracture is compound, 
it is often quite impossible to retain the forearm in the half-pronated 
position ; since, when thus placed, and only slightly supported, as it 
must necessarily be, it inevitably falls over upon its palmar surface. 
There can be no doubt that in such a case we ought, from the first, if it 
is found practicable, to place it upon its back, in a position of complete 
or nearly complete supination. For this purpose, a single broad splint, 
carefully cushioned, and covered with oiled cloth, is the most suitable. 
Upon this the forearm is to be laid, and secured gently with a few turns 
of the roller. If the patient is able to do so, and wishes to walk about, 
the board may be suspended to the neck. 

I have said that we ought, in cases of compound fracture, to lay the 
forearm upon its back, if practicable. I am sure, however, that the 
surgeon will find very many patients who cannot endure this position, 
and he may be compelled, therefore, to lay the limb upon its palmar sur- 
face, or to leave it to assume any other position in which it may be the 
most at ease. 

In conclusion, I desire again to call attention to the splint employed by Dr. 
Scott, and of which an illustration is given in the chapter which treats of Frac- 
tures of the Eadius. 

Of the 37 examples of delayed and non-union recorded by Muhlenberg, 30 
were subjected to treatment. Of 4 treated by manual friction, 1 was cured and 
3 failed. One treated by section was cured. Of 17 treated by resection, 11 
were cured and 6 failed ; 4 were treated by drilling, and all failed. Of 4 treated 
by mechanical appliances and immobilization, 2 were cured and 2 failed. 1 

1 Muhlenberg, Agnew's Surg., op, cit., vol. i. p. 805. 



FRACTURES OF THE METACARPAL BONES. 329 



CHAPTEE XXY. 



FRACTURES OF THE CAEPAL BONES. 

All of the cases of fracture of the carpal bones which have come 
under my observation were, without exception, compound and compli- 
cated, and have resulted in the complete loss of the hand, or in some less 
serious, but never inconsiderable, mutilation or maiming. In no case 
has a treatment been adopted which might be regarded as having refer- 
ence to the fracture, or the purpose of which was to insure apposition 
and union of the fragments. It may be proper to assume, in a matter 
so easily comprehended, what actual and recorded experience has not 
proven, namely, that simple fractures of these bones will demand very 
little surgical interference, and that they will unite generally without 
much displacement, and without any considerable maiming. It is, 
indeed, quite probable that some degree of ankylosis between their adja- 
cent surfaces will occur, yet even in the normal condition they enjoy so 
little motion as to render it doubtful whether its complete loss would be 
very sensibly felt. 

In cases of comminuted, compound, and otherwise complicated frac- 
tures of the carpal bones, which accidents are sufficiently common, the 
surgeon has only, I conceive, to follow carefully those general or special 
indications which may happen to be present, the precise character of 
which it would be difficult to anticipate, and for the treatment of which 
it would be unsafe to attempt in a written treatise to provide. 



CHAPTEE XXVI. 

FRACTURES OF THE METACARPAL BOXES. 

Development of Metacarpal Bones. — These bones are each formed 
from two centres of ossification. In the case of the metacarpal bones of 
the four fingers there is one centre for each shaft, and one for each distal 
extremity : but in the case of the metacarpal bone of the thumb there is 
one centre for the shaft and one for the proximal extremity. All these 
epiphyses unite with the shafts at about the twentieth year. 

Causes. — They are generally broken by direct blows; and in that case 
the injury is often of such a character as to demand amputation, and does 
not therefore belong to that class of accidents of which it is the purpose 
of this volume to treat. Not an inconsiderable number, however, are the 
results of indirect blows, and especially of blows upon the knuckles re- 



330 FRACTURES OF THE METACARPAL BONES. 

ceived in pugilistic encounters. Thus, in a record of sixteen fractures, 
I find this cause assigned in seven ; in one other instance it was occa- 
sioned by falling upon the clenched fist, and in one by striking a board ; 
so that the fracture has resulted from a blow upon the ends of the bones 
in nine of the sixteen examples. 

Point of Fracture ; Direction of Displacement ; Symptoms. — Once 
the fracture has occurred in the metacarpal bone of the thumb ; eight 
times in the metacarpal bone of the index finger; once in the second 
finger; three times in the ring finger, and three times in the metacarpal 
bone of the little finger. Two of those belonging to the ring finger, and 
the three occurring in the little finger, were produced by blows with the 
clenched fist, and in each instance the fracture was in the lower or distal 
third of the bone. Three of the fractures of the metacarpal bone of the 
index finger were produced also in the same way ; two of which were 
near the middle of the bone, and one near the proximal end. Of the 
whole number, seven were broken through the lower third, five through 
the middle, and four through the upper third. 

In every instance where the bone is known to have been broken by a 
blow upon the knuckles, the distal end of the distal fragment was thrown 
toward the palm, and this fragment was salient backward at the point of 
fracture. 

In the following case the bone was probably separated at the epiphysis : 
T. R., set. 8, fell down a flight of steps, breaking the metacarpal bone of 
the index finger of the right hand near its lower extremity, and apparently at 
the junction of the epiphysis with the diaphysis. The lower fragment, project- 
ing abruptly into the palm of the hand, could be easily replaced, or with only 
moderate effort, yet immediately when the support was removed it would become 
displaced. There was no crepitus. It was dressed very carefully with a splint 
and compress ; but, notwithstanding our continued efforts to keep the fragments 
in place, the epiphysis united considerably depressed toward the palm. 

In one instance, also, I think the bone was rather bent, or partially fractured, 
than broken completely. This was a case of the fracture of the metacarpal bone 
of the ring finger, produced in a gymnasium by striking with the clenched fist 
against a board, and to which I have already alluded. I did not see the young 
man until four weeks after the accident, when I found the lower end of the bone 
depressed toward the palm, and the angle made at the point of fracture was 
rather rounded and quite smooth ; it was also tender at this point, but the bone 
was firm and unyielding. Four years after I was permitted to examine it again, 
and I found the same slight deformity still continuing. 

A partial explanation of the fact that the distal end of the distal frag- 
ment is generally displaced toward the palm, may be found in the natural 
curve of these bones, which is such that when the fracture has been pro- 
duced by a counter-stroke, the distal end would almost necessarily be 
driven in this direction ; and a farther explanation has been suggested 
by Mr. B. Cooper, namely, the action of the interossei. 

Prognosis. — Generally, when the fracture is simple, and the displace- 
ment is not considerable, the nature of the accident is overlooked, and 
some deformity must inevitably ensue. In a majority of the cases which 
have come under my observation this has been the fact, and the bone has 
remained slightly bent at the seat of fracture, but without affecting in 
any degree the value of the hand. 



FRACTURES OF THE METACARPAL BONES. 331 

The following example has furnished the most serious result of any case of 
simple fracture of these bones which has come under my notice: L. M. , set. 
25, struck a man with his clenched fist, breaking the metacarpal bone of 
the index finger of the right hand near its middle.. Great swelling and sup- 
puration followed the injury. Nearly four months after the injury was received 
there existed a complete ankylosis at the wrist-joint, and a partial ankylosis in 
the fingers. The hand was deflected forcibly to the radial side. At the point 
of fracture the fragments were salient backward and quite prominent, but firmly 
united. 

Even when the existence of the fracture is recognized, it is not always 
easy to retain the fragments in place. 

Miss E., of Erie, N. Y., set. 18, fell, striking upon her right hand with 
her fingers forcibly bent into the palm of the hand. On the following day she 
consulted me at my office, and I found the metacarpal bone of the ring finger 
broken at about three-quarters of an inch from its distal end, and the distal ex- 
tremity of the fragment depressed toward the palm. A feeble crepitus, with 
distinct motion, completed the diagnosis. The young lady was very anxious to 
have a perfect hand, and I was determined if possible to accomplish it. Find- 
ing that the joint end of the distal fragment w T as constantly disposed to fall 
toward the palm, I constructed a gutta-percha splint for the hand and fingers, 
and after placing a pad directly underneath this fragment, I secured it firmly 
with a roller. From this time until the end of four weeks she remained under 
my care, visiting me as often as once or twice a week, and at each dressing I 
found the distal fragment slightly displaced in the same direction as at first, nor 
was I able ever to make it resume completely its position. 

Ordinarily, however, no such difficulty is experienced, and the bone, sup- 
ported by simple means, unites quickly and without deformity. 

An engineer was struck by a piece of iron in such a way as to break his right 
forearm and the second metacarpal bone of the same hand. The fracture of the 
metacarpal bone was compound and about three-quarters of an inch from its 
proximal extremity. When he called upon me, which was immediately after 
the injury was received, I found the proximal fragment projecting directly back- 
ward, its sharp point rising above the skin, into Avhich position it was evidently 
drawn by the action of the extensor carpi radialis longior muscle. By pressure 
alone it could be replaced, but it was much more easily reduced when the hand 
was forcibly carried backward on the forearm. I therefore secured the hand in 
this position with appropriate splints, and it was maintained in this posture 
during most of the subsequent treatment. Union finally took place, but not 
without some backward displacement. Four months after the accident occurred 
I examined the hand, and found the skin healed over completely, the end of the 
fragment having become rounded and smooth, so as not to give him any degree 
of annoyance. His wrist was as flexible and as strong as before. No doubt the 
projection of the fragment might have been prevented entirely by cutting at the 
point of its attachment the tendon of the muscle, but this would have sensibly 
weakened the wrist-joint, and I preferred the alternative of a projection of the 
fragment. 

Treatment. — With moderate extension made upon the finger corre- 
sponding to the broken bone, while the fragments are forced home by 
firm pressure, the bone may generally be brought at once into line, and 
we may now proceed to adapt a gutta-percha, felt, or thick pasteboard 
splint, to either the whole surface of the back or palm of the hand and 
fingers, while they are held in a position of easy flexion. It is not very 
material to which of these surfaces the splint is applied ; or rather, I 
may say, it ought to be applied to the one or the other according as cir- 
cumstances seem to indicate. It should be well padded, and especially 
at certain points, in order to the more effectual support of the fragments. 



332 FRACTURES OF THE FINGERS. 

It is then to be secured in place with several turns of a roller. When 
either of the metacarpal bones, except those of the great or ring finger, 
is broken, the splint must be wide enough to secure the sides of the hand 
against the pressure of the roller. Thus dressed, the hand may be laid 
in a sling beside the chest, or while sitting it , may rest upon a table. 
The apparel must be examined daily, and readjusted as often as it shall 
become disarranged, or as a doubt shall arise as to the condition of the 
parts. When the fracture is followed by much inflammation, or occurs 
near, and especially if it actually involves a joint, the same precautions 
must be adopted to prevent ankylosis as in the case of similar fractures 
in other bones. 



CHAPTEE XXVII. 

FBACTURES OF THE FINGERS. 

Development of the Phalanges of the Hand.— The phalanges of the 
hand are formed from two centres of ossification, namely, one for each 
shaft and one for each proximal end. Ossification commences in the 
shafts at about the sixth week ; in the epiphyses of the first phalanges 
between the third and fourth years, and in the epiphyses of the last two 
phalanges somewhat later. Complete bony union takes place between 
the epiphyses and the shafts at from the eighteenth to the twentieth 
year. 

Causes. — I do not remember to have seen a fracture of one of the 
phalanges produced by a counter-stroke; I am aware, however, that 
they are occasionally produced in this way, as by falling upon the ends 
of the fingers, and especially by the stroke of a ball in the game of base. 

The fact, however, that they are generally the consequence of a direct blow, 
and that the finger bones are small and only protected by a thin covering of skin 
and tendons, renders them peculiarly liable to comminution and to other serious 
complications. Thus, in a record of thirty fractures, only eighteen were suffi- 
ciently simple to warrant an attempt to save them ; and only five are recorded 
as simple fractures without complications. 

Point of Fracture and Direction of Displacement. — In the following 
case there was probably an epiphyseal disjunction : 

A lad four years old had a simple fracture of the first phalanx of the ring 
finger of the left hand, the fracture being at the proximal end of the bone, and 
at the junction of the epiphysis with the shaft. 

The finger was so much swollen at first, that no dressings were applied until 
the fifth day, at which time a gutta-percha splint was moulded to it carefully. It 
resulted in a perfect cure. 

I have not seen the fragments much overlapped, except in one in- 
stance. Occasionally there has been no perceptible displacement ; but 
generally there will be found a slight displacement in the direction of 
the diameter of the bone. 



FRACTURES OF THE FINGERS. 333 

The case to which I refer as presenting an extraordinary overlapping was that 
of an Irish laboring woman, aged about thirty-five years, who, having fallen 
down a flight of steps, broke the first phalanx of the thumb below its middle. 
The distal fragment was displaced backward, overlapping the proximal fragment 
a little more than one-quarter of an inch. We made repeated efforts, by pulling 
upon the thumb with a sliding noose, and with all the strength of our four 
hands, but to no purpose. The fragments could not be reduced for one moment; 
and we left the patient as we had found her, only somewhat the worse for our 
violent and repeated extensions and manipulations. The finger was already 
considerably swollen when we began our efforts, and we cannot, therefore, say 
what might have been accomplished at an earlier moment, but I must confess 
that our defeat was unexpected, and does not seem to me to be satisfactorily 
explained. 

Prognosis. — At least ten have left no appreciable lameness or deformity, 
and possibly several more. It is, therefore, probably true that these con- 
sequences may be avoided with proper care in one-half of the examples 
in which we attempt to save the finger ; and perhaps it will occasion 
surprise that a perfect result may not be claimed in a larger proportion ; 
but when we consider how frequently the accident is compound, and that 
even when it is not, the blow having generally been received directly 
upon the point of fracture, how promptly swelling ensues, it will be easily 
understood that it will be often found difficult to determine whether the 
bone is exactly in line or not, or to maintain it in this position after 
absolute coaptation has been once secured. I have seen the finger in two 
or three cases deviate laterally, or become permanently deflected to one 
side or the other ; and once I have found it united, but rotated on its 
own axis. This latter case is not without instruction. 

A girl, set. 6, had her little finger caught by a door violently shut, breaking 
one of the phalanges, and nearly severing the finger. I closed the wound, and 
dressed the finger with a moulded pasteboard splint. My dressings were repeated 
often, and applied carefully; nor did I detect the rotation which the lower frag- 
ment had made upon its own axis until the union was consummated. I then 
found the extremity of the finger turned so that its palmar surface presented 
diagonally toward the ring finger. 

Treatment. — Boyer, and after him Bransby Cooper, have taught that 
when the extreme phalanx is broken, from the small size of the bone, 
and from its having attached to it the nail and its matrix, it is better in 
all cases to amputate at once, as the process of reparation is in such case 
extremely slow and uncertain. Examples must, no doubt, sometimes 
occur, in which the fracture is so simple in its character as to render 
prompt reunion pretty certain ; and even though the restoration should 
prove tedious, this ought scarcely to be regarded as a sufficient justifica- 
tion for so serious a mutilation as these surgeons propose, since the loss 
of even an extreme phalanx is not only a deformity, but must prove in 
many occupations a troublesome maiming. 

Prof. Lizars, of the Toronto School of Medicine, C. W., has reported to me 
a case exactly in point: "A man fractured the distal extremity of the ring 
finger of the right hand. The fracture was transverse, and the nail was severely 
bruised, the accident being caused by a direct blow. Crepitus distinct. A 
dorsal splint and bandage were applied, and in a short time the fragments were 
united firmly by bone. The nail subsequently fell off, and a new one was 
formed." 



331 FRACTURES OF THE FINGERS. 

The rule ought still to be held inviolate, which surgeons have so often 
repeated in reference to injuries inflicted upon the hand and fingers, 
namely, that we should save always as much as possible. It is remark- 
able, too, how much nature, assisted by art, can do toward the accom- 
plishment of this purpose. If the bone of a finger is not only severed 
completely, but also all of its soft coverings, save only a narrow band of 
integument, are torn asunder, a chance remains for its restoration. 
And it is especially interesting to observe what recuperative powers are 
possessed by the articular surfaces of these smaller joints, so that although 
they may be broken into, or sawn through, or comminuted, and although 
small fragments be entirely removed, a complete restoration of their 
functions is sometimes permitted. I have seen and reported some such 
examples. It is true, however, that such fortunate results are rare, and 
they are rather to be hoped for than anticipated. 

Fig. 183. 




Gutta-percha splint for finger. 

Since, in the case of these delicate bones, the slightest deviation from 
the natural form or position determines in the end an ugly deformity, it 
becomes exceedingly necessary, especially with females, that we should 
open the dressings and examine the fingers carefully from day to day, so 
that, as the swelling subsides, we may discover and correct any displace- 
ment which may happen to exist. As a splint, I have found nothing so 
convenient as gutta percha, moulded accurately to either the dorsal or 
palmar aspect of the finger ; and the form of which I have found it 
generally necessary to change slightly every third or fourth day, until 
consolidation is nearly or quite completed. If the fracture is near or 
extends into a joint, the finger ought to be a little flexed, so as to place 
it in the most useful position in the event that ankylosis should occur ; 
and as early as the end of the second week the joint surfaces should be 
slightly moved upon each other, in order to the prevention of fibrous or 
bony adhesions. Nor is there much danger of preventing the union of 
the bone by moving the joints at this early day. Union occurs between 
these fragments very speedily, and I have never met with a case of non- 
union of the phalanges, nor do I remember to have seen a case reported. 

It is the lateral inclination of the distal end of the finger which, ac- 
cording to my experience, it will be found most difficult to obviate, and 
which may, perhaps, in some cases be most successfully combated by 
laying the two adjoining sound fingers against the broken finger, and 
then applying a moulded splint to the palmar surface of the whole. In 



FRACTURES OF THE PELVIS, 



335 



other cases it will be more convenient to apply the splint only to the 
broken finger. Rotation of the lower fragment on its own axis is espe- 
cially to be guarded against, as the deformity which it occasions is more 
unseemly, and the impairment of utility more decided, than that occa- 
sioned by a lateral deviation. It may be well also to remind the surgeon 
of the convenience of extending the splint beyond the end of the last 
phalanx, and moulding it to this extremity, in order that the finger may 
be protected against injuries^ and that when, from time to time, the 
splint is removed it may be reapplied with accuracy. In all cases the 
splint should be lined with cotton cloth, soft flannel, or sheet lint, and 
secured in place with narrow and neatly cut cotton rollers. Bandages 
of this width should never be torn, but carefully cut with scissors. 



CHAP TEE XXVIII. 

FRACTURES OF THE PELVIS, AND TRAUMATIC SEPARATIONS 
OF ITS SYMPHYSES. 



Development of the Os Innominatum (Fig. 184). — This bone is formed 
from eight centres, three of which are called primary, and five secondary. 



Fig. 184. 




Development of the os innominatum. (Gray.) 

The three primary centres belong respectively to the ilium, ischium, and 
pubes, and by their extension form eventually the greater portion of the 



336 



FRACTURES OF THE PELVIS. 



innominatum. They have a common point of union in the acetabulum ; 
and the ischium unites with the pubes, also, by the junction of their 
rami. These conjunctions occur usually between the fifteenth and twen- 
tieth years of life. The secondary centres do not begin to ossify until 
the age of puberty, and may, therefore, properly be considered as 
epiphyses. One forms the crest of the ilium ; one its anterior inferior 
spinous process ; one forms the symphysis pubis ; one the tuberosity of 
the ischium ; while the fifth constitutes the centre of the bottom of the 
acetabulum. The epiphyses become joined to the primary bones, or the 
bodies of the innominata, at about the twenty-fifth year. 

[Fracture of the pelvic bones is usually caused by a crushing injury, as by a 
wheel passing over the pelvis, or a heavy weight falling upon it, as a bank of 
earth. These fractures are rarely single, and generally there are several parts 
involved. (Fig. 185.) Frequently these injuries not only cause fractures, but im- 
plicate the viscera of the pelvis, especially the bladder. And it is in this latter 
complication that their danger largely depends. Bryant, of London, had under 



Fig. 185. 



Fig. 186. 





Fracture of the pelvic bones. (Bryant.) 



Fracture of the pelvis of a child with 
separation of the pelvis, prolapse of the 
rectum and uterus. (Bryant.) 



his care a child suffering from fracture of the pelvis, the whole pelvic organs 
having been pressed out of the outlet by the crushing force ; the large intestine 
for about a foot, uterus, bladder, etc., were all in view, the whole perineum 
having been ruptured. And yet she survived the injury, though fourteen months 
after the accident there was a prolapse of the rectum and uterus. However com- 
plicated the case may be there is often a chance of recovery. (Fig. 186.)] 

§ 1. Pubes. 

Separations at the Symphysis Pubis. — Lente mentions the case 
of a youth, aet. eighteen years, who was crushed between a couple of 
cars, in consequence of which he died two days after. The autopsy 
disclosed a separation of the symphysis pubis, unaccompanied with any 
other fracture. The right side was displaced backward about half an 
inch, so that the fingers could be passed between the bones. There was 
also a wound in the top of the bladder large enough to admit the thumb. 1 
Similar accidents have been several times met with by surgeons. Hall 



Lente, New York Journ. Med., 2d ser., vol. iv. p. 286. 



pubes. 337 

reports a case in which the pubes, thus separated, was actually thrust 
into the bladder ; but in this example the ilium was broken also. This 
patient died. 1 Sir Astley Cooper has furnished an example of a simple 
fracture or traumatic separation at the symphysis, from which the patient 
after a long time almost completely recovered. The following is Sir 
Astley 's account of the case : 

"R. W., set. twenty-two years, sustained a severe injury in consequence of a 
large quantity of gravel having fallen upon his back while in the act of stoop- 
ing. It knocked him down ; and on rising, which he did with considerable dif- 
ficulty, he attempted to walk ; this produced violent pain in the region of the 
bladder, extending upward in the course of the ureters to the kidneys. Upon 
inquiry, he stated that the urine he had voided since the accident was bloody and 
passed with difficulty. A fissure was found at the symphysis pubis, producing 
a separation of about two fingers' breadth. On pressure being made upon any 
part of the ilium, he complained of increased pain in the region of the pubes, 
and of numbness down the left thigh. A catheter was immediately passed, and 
the urine which was drawn off was clear and healthy. He remained in the hos- 
pital for three months w T ithout any check to the progress of his cure ; the length 
of time it required being accounted for by the difficulty of reparation in the 
amphiarthrodial articulation ; and when he left there was some slight separation 
of the pubes remaining ; nor were the two lower extremities, or the anterior and 
superior spinous processes of the ilia, perfectly symmetrical, although he could 
walk very well." 2 

Malgaigne has collected four cases of simple separation at the sym- 
physis pubis occasioned by external violence, and in three of the four 
cases it was occasioned by pressing out the thighs with great force ; the 
separation being directly due, therefore, to muscular action. Two of 
these patients succumbed to the accidents. The same author has brought 
together, also, seventeen cases of separations of this symphysis occurring 
in childbirth, of which only seven survived. 

[Gay, 3 of Boston, saw a case of separation of the symphysis caused by injury 
from the pommel of the saddle, owing to a fall while riding on horseback. An 
abscess formed, and on being opened the separation at the symphysis and mo- 
bility of the bones could be detected with the finger. He recovered.] 

True Fractures of the Pubes. — It is much more common, however, to 
find the pubic bone broken through its horizontal or ascending ramus. 

Clark, of the Massachusetts General Hospital, has described a case of simul- 
taneous fracture of the pubes and ischium in three places. The man, set. twenty- 
nine years, had been caught between two heavy timbers. No crepitus could be 
detected, but he was unable to lie upon the right side, and the right limb was 
nearly paralyzed. It was evident that the bladder or urethra had'been ruptured, 
and on the third day Dr. Clark opened the bladder through the perineum, evacu- 
ating a large amount of blood and urine, and affording to the patient very sensible 
relief. He died, having survived the accident twenty-five days. The autopsy 
disclosed several fractures, all of which belonged to the right os innominatum. 
First, a fracture of the pubes near the symphysis ; second, a fracture near the 
junction of the pubes and ilium ; third, a fracture through the ramus of the 
ischium anterior to the tuberosity.* Sir Astley mentions a case of fracture of the 
" ramus of the pubes," unaccompanied with injury to the bladder or urethra, 

1 Hall, Anier. Journ. Med. Sci., vol. xxxiv. p. 248. 

2 Sir Astley Cooper, Frac. and JJisloc., Amer. ed., p. 144. 

3 Med. and Surg. Reports of the City Hospital of the City of Boston, 1889. 

4 Clark, Boston Med. and Surg. Journ., vol. liii. p. 185. 

22 



338 



FRACTURES OF THE PELVIS. 



Fig. 187. 




Clark's case of fracture of the pelvis. 



which resulted in a complete recovery, and in another case the patient recovered 
in eight weeks, and was able to walk nearly as well as before; he died of 

disease of the chest. The os pubis was 
found, at the autopsy, to have been 
broken in three places; there was also 
a fracture extending in two directions 
through the acetabulum, with an exten- 
sive comminuted fracture of the ilium, 
accompanied with great displacement. 
Marat, after a fracture, removed nearly 
the whole of the body of the pubes by 
incision, in a girl of eighteen years, and 
who not only recovered completely, but, 
having subsequently married, she gave 
birth to two children in easy and natural 
labors. 1 

[Browne had a case of fracture of the 
rami of both pubic bones, as proved by 
the autopsy. They were caused by the 
fall of a heavy weight. On one side the 
epigastric artery had been torn off. 2 ] 

Cappelletti relates that a man, set. 44, 
jumped from a carriage, the horses having 
run away, and alighted with his feet to 
the ground, but with one limb in the 
greatest possible degree of abduction. 
Six months after there remained a slight swelling near the ramus of the ischium 
and pubes, under which a careful examination detected a fragment of bone two 
and half inches long and of the " size of the finger." The patient was able to 
walk, but not without pain and limping. On examining anteriorly, Cappelletti 
found this part of the pelvis defective, and the loose portion of the bone had 
all of the anatomical characters of the defective part. 3 

Whitaker, of Lewistown, N. Y., saw the body of the left os pubis broken in a 
female while in the seventh month of pregnancy. She had fallen down a flight 
of stairs, striking astride the edge of an open, upright barrel. The fracture was 
oblique, and with but little displacement; yet she complained of excruciating 
pain in the left pubic region on the least motion. The accident was followed by 
no positive attempt at miscarriage. 4 

[Fay, of Denver, had a case caused by a falling bank, in which the fracture 
was compound. The horizontal ramus was broken, but without any injury of 
the bladder. 5 

Allis, 6 of Philadelphia, discussing fractures and disjunctures of the pelvis, 
regards the pelvis as a single structure, like the adult skull, and so compactly 
joined at the symphysis that separation without violence to bony connections is 
practically impossible. From a clinical standpoint he considers the pelvis as a 
single bone. The main sources of danger in injuries of the pelvis are to the 
genito-urinary apparatus, and the bloodvessels. These injuries, he believes, are 
due to the spreading apart of the bones, " the effect of a sudden expansion of 
the pelvic girdle," rather than to the fractures. The soft tissues, as the urethra 
and large veins and arteries, are torn or lacerated, and not cut.] 

Prognosis. — The danger in these accidents consists not so much in the 
fracture, as in the injury done to the bladder and other pelvic viscera. 
If the bladder is opened into the peritoneal cavity, death is almost inevit- 



1 Marat, from Malgaigne, op. cit., p. 646. 

2 London Lancet, 1889, vol. i. 

3 Cappelletti, Banking's Abstract, No. viii. p. 83: from Giornale per servire al Progress! 
della Patologie della Terapeutica. 1847. 

4 Whitaker, Amer. Journ. Med. Sci., July, 1857, p. 283. 

5 Denver Med. Times, Jan. 1885. 

6 Trans. Amer. Surg. Assoc, vol. viii. 1890. 



ischium. 339 

able ; and even when the bladder or urethra has suffered laceration lower 
down or at any point above the deep perineal fascia, extensive urinary 
infiltrations, followed by abscesses and gangrene, generally expose these 
patients to the most imminent hazards. 

Treatment. — The practice pursued at Guy's Hospital, in the case of 
separation at the symphysis pubis, commends itself both by its simplicity 
and by its success. Antiphlogistic remedies steadily pursued, rest in the 
recumbent posture, the use of the catheter when necessary, and in certain 
cases the girding of the pelvis with a firm belt or band, are measures 
which seem to meet all of the important indications. If the fracture is 
accompanied with displacement, it will be proper to attempt to restore 
the fragments ; but, except in the case of separation at the symphysis, 
very little aid can be expected from a band or any similar means in 
retaining them in place. It will be sufficient, generally, in such examples 
to place the patient quietly upon his back, with his thighs flexed upon 
his body, and to treat the accident in all other respects as a case of in- 
flammation. If the urine has become extravasated underneath the pelvic 
fascia, no time ought to be lost in opening freely through the perineum, 
and in extending the incision, if necessary, into the urethra and bladder. 

§ 2. Ischium. 

When speaking of fractures of the pubes, I have already mentioned 
some examples of fractures of the ischium also ; indeed, it is seldom that 
one of the bones of the innominatum is broken without a coincident 
fracture of one or both of the others. The records of surgery furnish 
several other examples, produced gener- 
ally by a fall upon the tuberosities : Fig. iss. 
but, perhaps, the most remarkable in- 
stance is that mentioned by Marat as 
havino- occurred in a female during 
labor. 

The following summary of a case of frac- 
ture of the ischium, reported by Sir Astley 
Cooper, will serve to illustrate one of the 
most fortunate terminations of these acci- 
dents when accompanied with a rupture of 
the urethra : A young man who was driving 
a cart was thrown down, and a wheel 
passed over him. On the following morning he was found to have a fracture 
of the left leg and a contusion of the inner side of the left thigh. There was 
also great swelling and ecchymosis of the scrotum, with a slight appearance of 
injury over the pubes and left hypochondrium. Xo fracture of the pelvis was 
at that time discovered. The patient was suffering great pain, and w T as cold and 
exhausted. Bloody urine escaped from the bladder. On the eigth day an 
abscess had pointed on the left side of the perineum, which, being opened, dis- 
charged a large quantity of pus having the odor of urine ; extensive sloughing 
occurred, and the patient sank very low. On introducing the finger into the 
wound, the ascending ramus of the ischium could be distinctly felt, and the 
fracture traced in an oblique course, the upper fragment being slightly displaced 
forward. When the catheter was introduced into the urethra it was found to 
enter this wound, and could be felt resting against the naked bone. From this 
time until the twenty-sixth day, the urine continued to escape freely through 




Fracture of the pubic and ischiatic 
bones. 



340 FRACTUKES OF THE PELVIS. 

the wound. In about six weeks more the fistulous opening had entirely closed, 
and after several months his recovery was complete. 1 

[Bennett, of Dublin, reports a dissecting-room case in which the ischium was 
found detached from the left innominate by fracture, which had traversed the 
junction of the bone with the ilium and pubis. The detached bone had been 
displaced backward and upward — a displacement which appears to have been 
limited by the ramus ischii catching against the pubic margin of the acetabulum ; 
in this position the ramus was united both to the pubis, where it forms the 
superior limit of the notch of the acetabulum, and to the descending ramus of 
the pubes ; the ramus ischii fills up the lower angle of the obturator foramen. 
Posteriorly the ischium is thrown across the great sciatic notch, which is reduced 
to a narrow slit just capable of transmitting the great sciatic nerve only; the 
displaced bone is united to the side of the sacrum, and to the posterior inferior 
spine of the ilium. In this displacement the head of the femur participated, and 
it rested much in the position commonly assigned to it in dislocation into the 
sciatic notch.] 

Symptoms. — The signs of this accident are generally even more obscure 
than those of fractures of the pubes, but in a case of doubt the bones 
ought not only to be carefully examined from without, but the finger 
should be introduced freely into the rectum and the anterior surface ex- 
plored ; or the tuber ischii may be grasped between the thumb and finger 
and moved laterally in order to determine the existence of motion or 
crepitus. If the patient is a female, this exploration can be best made 
through the vagina. By flexing and extending the thigh, also, crepitus 
may sometimes be discovered. The examination will generally be made 
while the patient lies upon his back ; but if turning is not found too 
painful, it will be well to lay him upon his face, that the tuberosities of 
the ischium may be more plainly brought into view. 

Prognosis. — A considerable proportion of the fractures of both the 
pubes and the ischium are accompanied with lesions of the bladder or of 
the urethra, either of which circumstances will render the prognosis very 
unfavorable ; but in simple fractures recoveries , may generally be ex- 
pected, yet only after a tedious confinement. 

Treatment. — It is not usual, except in cases which must almost neces- 
sarily prove fatal, to find much displacement of the fragments ; nor is it 
probable that by any manoeuvres the slight displacements which are found 
to exist can be entirely overcome. Instances may occur, however, in 
which careful pressure from without, or the introduction of a finger into 
the rectum or vagina, may aid in the restoration. The posture best 
suited to these cases will be indicated usually by the sensations of the 
patient himself. Ordinarily he will prefer to lie upon his back with his 
thighs flexed and supported by pillows ; and his hips slightly elevated 
by a firm cushion laid under the upper part of the sacrum. His knees 
ought also to be gently bound together ; but if the patient finds this 
position painful or excessively irksome, as sometimes he will, he may be 
permitted to occupy any position which he finds most comfortable. 

§ 3. Ilium. 

Fractures of the ilium are much more common than fractures of either 
the ischium or pubes, and they assume a great variety of forms, direc- 
tions, and degrees of complication. 

1 Sir A. Cooper, by Bransby Cooper, Amer. ed., p. 140. 



ILIUM. 341 

In the two following examples the anterior superior spinous process alone was 
broken off: J. K., set. 36, was admitted to the hospital, having just fallen and 
broken the anterior superior spinous process of the ilium. The fragment was 
displaced downward about one-quarter of an inch. Motion and crepitus dis- 
tinct. A slight ecchymosis existed over the point of fracture, and other signs 
ot contusion about the hip were present. He was intoxicated at the time of 
the accident, and could not tell how or where he fell. He was laid upon his 
back in bed, with his thighs flexed upon his body ; and in this position we 
attempted to reduce the fragment and retain it in place with a bandage ; but 
finding this impossible, we left him with only instructions to remain quietly in 
bed. In about two weeks the fragment was firmly fixed in its new position, and 
he was allowed to get up and walk about, which he was able to do without in- 
convenience. M. was caught under a bank of earth. He was unable to stand 
upon his feet. There was a lacerated wound and an extensive bruise on his left 
hip ; but the thigh was not shortened nor everted, and he could flex it slightly 
upon his body. Noticing a swelling and discoloration in the region of the 
anterior superior spinous process of the ilium, I pressed upon it and felt it 
recede with a distinct crepitus ; the fragment, however, immediately resumed 
its place -when the pressure was removed. I was able, also, by a careful 
manipulation, to trace the line of fracture, and to determine that it included a 
small portion of the anterior extremity and wing of the pelvis. We directed 
the patient to remain quietly upon his bed, with his legs drawn up. He soon 
recovered, but I am unable to say what is the present position of the fragment. 

In the case of M., set. 60, admitted to Bellevue, the fragment was displaced 
downward one inch, and could not, by flexion of the limb, be replaced. It was 
not united at the end of three weeks. The ability to move his limb was unim- 
paired. • 

More frequently, however, the fracture involves a larger portion of the crest. 
J. J., set. 40, was caught by the bumpers between two cars, breaking ob- 
liquely the anterior superior portion of the ilium. I saw him within an hour, 
and found him greatly prostrated ; the fragment of the pelvis broken off was 
quite movable, and crepitus was easily detected. His abdomen was very tender 
and slightly tympanitic. He was laid upon his back with his legs drawn up, 
and hot fomentations were directed to be applied to his belly. The broken ala 
did not seem disposed to become displaced. With no other treatment, his re- 
covery was rapid; and the bones seemed to have united without displacement. 

J. R., set. 41, fell from a height of fourteen feet, breaking off the anterior 
superior portion of the right ala of the pelvis. The fragment, which was quite 
large, was movable, and occasionally a crepitus could be detected. It was dis- 
placed downward and forward about three-quarters of an inch. He was laid 
upon his back, with his thighs and limbs moderately flexed. At the end of two 
weeks he was able to walk without much difficulty, and he immediately left the 
hospital. At this time the fragment was displaced in the same manner and 
direction as at first, but I cannot say whether it had united or not. 

In one case the fracture was caused by the muscular action. W. A., aet. 
70, after riding in a railroad car about half an hour, arose to leave his seat, 
when he felt " something wrong" in his right groin, and lound himself unable 
to walk without great pain. He was admitted to Bellevue Hospital on the same 
day, and I found a fracture involving about three inches of the ilium, including 
the anterior superior spinous process. It was inclined to fall outward, but was 
easily replaced with a distinct crepitus. 

I have once seen a fracture of the posterior superior spinous process, 
and I do not know of any other example. 

Miss B., set. 19, was thrown from her horse backward, striking with her 
back upon the ground. She did not come under my care until two weeks after 
the accident. I found a small fragment broken from the posterior superior 
spinous process of the ilium, and displaced backward in the direction of the 
spine about half an inch. It was movable, and by pressure it could be partially 
restored to place, but it would immediately return to its abnormal position when 
the pressure was removed. The injured hip was painful, and occasionally numb. 



342 FRACTURES OF THE PELVIS. 

She had previously suffered from irritation. I laid a compress behind the frag- 
ment, and secured it in place with a roller, enjoining perfect rest. She recovered 
from her lameness in a few weeks, but I believe the fragment remains displaced. 

Prognosis. — Extensive comminuted fractures of the ilium are gener- 
ally accompanied with so much injury of the pelvic viscera as to prove 
rapidly fatal ; but the following examples will show that this rule admits 
of exceptions : 

B. D., set. 32, was crushed under a very heavy stone which fell upon his 
back. I found the left ala of the pelvis broken into several fragments be- 
tween the different portions of which motion and crepitus were distinct. The 
fractures were near the superior part of the bone, commencing about two inches 
back of the anterior superior spinous process, and extending backward irregu- 
larly. There was a narrow wound communicating with the fracture, from which 
I removed a loose fragment of bone. The right leg was also broken. Four 
months after, he was still confined to his bed, and a fistulous opening continued 
opposite the point of fracture; there existed also a large and irregular mass of 
ossific matter or callus around the fragments. He soon after left the hospital. 
Dr. Sargent, of the Massachusetts General Hospital, has reported a case in 
which a man received a compound fracture of the left ilium, and several small 
fragments were removed. He was discharged at the end of three months, with 
a fistulous opening still remaining, but in other respects he was quite well. 1 Dr. 
Cheever, of the same hospital, reports a case of fracture of the ilium, with frac- 
ture of the ascending ramus of the pubes, resulting in complete recovery ; but 
the leg became shortened and the toes inverted. Dr. Cheever believes that the 
lines of fracture met in the acetabulum. 2 

The following cases illustrate the more fatal injuries of this character: 
J. O'K. was crushed under a heavy stone, breaking and comminuting the alas 
of the pelvis on both sides, and wounding also the iliac vein. He was taken to 
the hospital, and died in a few hours, partly from shock from hemorrhage. 
Lucas 3 has also recorded two cases of lesion of this vein due to the same cause. 
Lente, of the New York Hospital, has reported a case of dislocation of the 
hip, which was accompanied with a fracture also of the ala of the pelvis upon 
the same side. The dislocation was reduced on the third day, and the patient 
soon after died. The autopsy disclosed what had not been suspected during life, 
namely, that the left ilium was broken horizontally about through its middle, 
and vertically through the crest ; and also that there was a fracture extending 
through the sacro-iliac synchondrosis, accompanied with considerable comminu- 
tion of the articular surfaces. It was found that a portion of the small intestine 
was ruptured, and probably by one of the sharp fragments of the broken pelvis.* 

It is seldom, I think, that the fragments become much displaced ; such, 
at least, has been my experience ; and I have noticed in Dr. Neill's 
cabinet three specimens of fracture of the crest of the ilium, all of which 
had united without any appreciable displacement. Dr. Neill also called 
my attention to the fact that in two of these specimens the ensheathing 
callus was confined to the outer surface of the bone ; an observation 
which, this gentleman assures me, he has had frequent occasion to make 
before where the fracture belonged to a flat bone. If any displacement 
exists, the upper or loose fragment is generally carried slightly inward ; 
occasionally, however, it is found displaced upward, outward, or down- 
ward. 

Treatment. — In a large majority of cases the fragments, if displaced, 

1 Sargent, Boston Med. and Surg. Journ., vol. liii. p. 121. 

2 Cheever, Boston Med. and Surg. Journ., May 3, 1866. 

3 Lucas, The Lancet, 1878, vol. i. p. 147. 

4 Lente, Kew York Journ. of Med., Jan. 1851, p. 29. 



ACETABULUM. 343 

cannot be completely replaced. Occasionally, however, as where the 
anterior superior spinous process is broken off with only a small portion 
of the crest, the fragment may be seized with the fingers and carried 
outward or upward, or in whatever direction may be necessary ; but 
to retain it in this position is generally quite impossible. The bandage 
or broad belt wdiich we have recommended in certain fractures of the 
pubes would be in these cases not only useless, but absolutely mischiev- 
ous, since its effect must be to press inward the fragments, and thus to 
create a displacement which might not otherwise exist. 

The surgeon ought to determine by a careful examination the extent 
and direction of the fracture, and, having done what was in his power to 
replace the fragments, he should lay his patient upon his back, with the 
thighs drawn up and supported. This is the position which will gener- 
ally be found most comfortable ; but, as in other fractures of the pelvis, 
it may be well always to try the effect of other positions, and especially 
to determine their influence upon the fragments, and finally to adopt that 
precise posture which accomplishes the indications best. 

If the fracture is compound, and the fragments have penetrated the 
belly, the wound should be enlarged, and, as far as possible, every piece 
of bone should be removed ; but if the fragments cannot be found, the 
external opening should be allowed to remain so as to favor their escape 
when suppuration shall have taken place. 

§ 4. Acetabulum. 

Although, strictly speaking, fractures of the acetabulum belong always 
to one or all of those bones of the pelvis whose lesions have already been 
described, yet the peculiar relations of this cavity to the femur render it 
necessary that they should be considered as a separate class of accidents. 

Fractures of the acetabulum divide themselves naturally into two 
varieties : 

First. Fractures of the base of the cavity, with or without displacement. 

Second. Fractures of the rim, with or without displacement. 

Fractures of the Base without Displacement. — In this species of frac- 
ture of the base of the cavity, nothing but crepitus can be present as a 
sign of the accident ; and this will scarcely be sufficient, in itself, to 
enable the surgeon to distinguish it from a fracture of the neck of the 
femur within the capsule without displacement. It is probable, there- 
fore, that its existence will only be determined by dissection. Nor is it 
of much importance that the diagnosis should be made out ; since in 
either case neither splints nor any other surgical appliances could be of 
service. An injury so severe as to fracture the acetabulum will neces- 
sarily so much bruise the body, and concuss the viscera of the pelvis, as 
to compel the patient to remain quiet for a number of days, and this is 
all that would be thought necessary if the nature of the accident was 
exactly determined. 

Dr. Neill's cabinet contains a specimen of this kind, in which the fracture, 
commencing near the centre, extends in three directions across the cotyloid 
margins, in which perfect bony union has occurred without displacement. 

M. Bouvier related to the Academy the case of a man, set. 71, who, in 
consequence of a fall from his bed, remained for three weeks unable to walk, 



344 



FRACTUKES OF THE PELVIS. 



and never was able afterward to walk without crutches. No fracture could be 
discovered during life, but after his death, which occurred some months subse- 
quent to the accident, a fracture was found extending from the ilio-pectineal 
eminence to the spine of the ischium, and traversing the centre of the ace- 
tabulum. The fragments were not displaced but remained slightly movable. 1 



Fig. 189. 



Fig. 190. 





Fractures of the acetabulum. 

Fractures of the Base with Displacement. — Fractures with the dis- 
placement of the femur into the pelvic cavity constitute a much more 
formidable, and unfortunately a more common form of accident. Like 
the preceding variety of acetabular fractures, they are produced generally 
by falls upon the trochanter major, but the force of the concussion has 
been greater. Even here, it is not often that the diagnosis has been 

clearly made out during life ; and indeed, 
generally, the true character of the accident 
has not even been suspected, the surgeons 
believing that they had to do with a fracture 
of the neck of the femur, or with a disloca- 
tion. 

In two examples mentioned by Sir Astley 
Cooper as having been presented at St. Thomas's 
Hospital, the thigh was thought to be dislocated 
backward. 

The following case was reported by Mr. Earle : 
A man, set. 40, was admitted with a severe 
injury, caused by having fallen from height of 
thirty-one feet, and striking. upon the left side. 
The left leg was powerless and shortened. The 
foot was everted. Any attempt to rotate the 
limb caused great pain, and was accompanied 
left trochanter was very much depressed, and 
hen it was pressed upon, the patient complained of deep-seated pain in the 




Head of femur driven through 
the acetabulum. 

with a sensible crepitus. The 



1 Bouvier, Amer. Journ. Med. Sci., vol. xxiii. p. 486 ; from Bullet, de l'Acad. Boy. de 
Med., August 15, 1838. 



ACETABULUM. 345 

hip-joint. He recovered in eight weeks, and was able to walk nearly as well as 
before; he died of disease in the chest. On dissection, a fracture was found 
extending in two directions through the acetabulum ; there was an extensive 
comminuted fracture of the ilium, with great displacement, and the os pubis was 
broken in three places. The repair was very complete, and Mr. Earle remarked 
how nature had guarded against any considerable deposit of new bone within 
the articulation, which might have interfered with the functions of the joint, 
while there was an abundant deposit of callus around the other parts of the frac- 
tured bone. 

[Holmes, 1 of London, reports a case of fracture of the acetabulum in which 
the head of the femur was driven through into the pelvis, as appeared at the 
autopsy.] 

Mr. Travers has reported two similar cases, and in the paper accompanying 
the report he maintains that very acute pain caused by pressing upon the pro- 
jecting spine of the os pubis, and the inability of the patient to maintain the 
erect posture, may be regarded as signs diagnostic of the accident. 2 It is doubt- 
ful, however, whether these phenomena, so common to many other accidents, 
could be relied upon as evidence of this peculiar lesion. 

[Gunn, 3 of Chicago, saw a boy who was thrown from a horse, striking the tro- 
chanter against a frozen lump of earth. There was flatness of the trochanter, 
but free flexion and extension, also rotation, abduction, and adduction. The 
diagnosis was made by examination per rectum, when the head of the femur was 
felt in the cavity of the pelvis.] 

In the following example reported by Lendrick, of Dublin, the patient was 
supposed to have a fracture of the neck of the femur : An old man was ad- 
mitted into the hospital suffering from phthisis pulmonalis and acute inflam- 
mation of the hip joint. Some years before, he had received a severe injury by 
the upsetting of a coach, and was under treatment several months for what was 
supposed to be a fracture of the neck of the femur. Since that time he had 
been lame, but still able to take a great deal of exercise on foot both in Great 
Britain and in America. The acute disease of the joint commenced about two 
months before his admission. This man died, and the dissection showed that 
there had been no fracture of the femur, but its head and neck were affected 
with "morbus coxas senilis." The head was also thrust through a rent in the 
acetabulum into the cavity of the pelvis ; but the head had again been covered 
by a bony case, complete, except in a small portion about the size of a shilling 
piece, and at this point the covering was ligamentous. The os pubis had also 
been broken at the same time, and it had united so much overlapped that the 
space between the inferior anterior spinous process and the symphysis pubis was 
shortened nearly an inch. A portion of intestine was found protruding through 
an opening in the pelvis and adherent to the bone, in which situation it seemed 
to have been caught by the broken fragments and retained. 4 

Morel-La vallee, in his thesis upon complicated luxations, mentions a case 
which had come under his observation, and which had been treated as a fracture 
of the neck of the femur. The patient survived the accident many years ; during 
a part of which time he suffered such pain in the hip-joint as to induce a belief 
that it was itself diseased. At his death he was found to have had a multiple 
fracture of the bones of the pelvis, and the head of the femur had penetrated 
more than an inch into the cavity of the pelvis, pressing upon the obturator 
nerve to such a degree as to have, no doubt, caused the severe pain from which 
he had suffered, and which had been ascribed to coxalgia. 5 

Symptoms. — In the two cases mentioned by Sir Astley Cooper as 
having been received into St. Thomas's Hospital, the toes were turned 
in. In the example mentioned by the same author as having been pre- 
sented to St. Bartholomew's Hospital, the toes were everted. 

1 Trans. Path. Soc. London, 1888. 

2 Travers, Holmes's System of Surgery, vol. ii. p. 478. 

3 X. Y. Med. Journ , Jan. 3. 1885. 

i Lendriek, Amer. Journ. Med. Sci., vol. xxiv. p. 481 : August, 1839 : from London Med. 
Gazette, March, 1839. 
5 Morel-Lavellee, from Malgaigne, op. cit., vol. ii. p. 8S1. 



346 FRACTUKES OF THE PELVIS. 

Moore has dissected a subject whose pelvis was broken into many fragments — 
the left os innominatum was divided into three portions, corresponding to the 
three bones of which it was composed in infancy ; the head of the femur had 
completely penetrated the basin ; the limb was shortened two inches, and in a 
position of slight flexion and adduction, but neither rotated outward nor inward. 1 

There seems, therefore, to be no certain rule in relation to the position 
of the limb; but it is found to take the one position or the other, probably 
according to the direction of the force which has inflicted the injury, and 
perhaps in obedience to circumstances not always easily explained. The 
shortening has been observed to vary from half an inch to two inches or 
more ; the trochanter is also usually driven in toward the pelvis. Pres- 
sure upon the trochanter occasions a deep-seated pain. If the limb is 
drawn down to the same length with the other, it immediately resumes 
its position when the extension is discontinued. Crepitus is more uni- 
formly present than in fractures of the neck of the femur, and it is 
especially felt while the limb is being extended or while it is again short- 
ening, and not so much in flexion or rotation. 

Diagnosis. — If, in addition to these facts, we learn that the accident 
has occurred from a severe blow, or a fall from a great height upon the 
trochanter ; and that the viscera of the pelvis, and especially the bladder, 
seem to have suffered considerable injury ; or if we detect at the same 
time a fracture of some other portion of the pelvis — we may reasonably 
conclude that the head of the femur has penetrated the acetabulum. 
Yet it must be confessed that no one of these symptoms is positively 
distinctive of this accident, and that they are seldom found sufficiently 
grouped to render the diagnosis certain. Possibly the displacement may 
be detected by the finger introduced into the rectum or vagina. 

The old "piper" mentioned by Lendrick, and the man dissected by Morel- 
Laval lee, lived many years, and managed to walk about, but not without con- 
siderable pain ; the other three, to whom I have alluded, died soon after the 
injuries were received. 

Treatment. — Some have thought of treating these cases by extension 
and counter-extension ; the latter being accomplished through the aid of 
a perineal band ; but it is not probable that after an injury of this char- 
acter, any patient will be able to endure the requisite pressure about the 
perineum or groins. It will be better to lay the patient upon Daniel's 
invalid bed, or some bed similarly constructed, so that it may be con- 
verted into a doubled-inclined plane ; allowing the knees to be suspended 
over the angle thus formed, in order that the weight of the body may 
have some effect to draw away the pelvis from the femur. Or we may 
adopt extension without the perineal band, as will be described hereafter 
when treating of fractures of the femur ; or we may resort to Hodgen's 
suspension apparatus. 

Fractures of the rim of the acetabulum have frequently been dis- 
covered in dissections ; and the records of surgery abound with cases of 
unreduced dislocations of the femur, in which the failure to reduce or to 
retain the bone in place has been ascribed, not always with sufficient 
reason, perhaps, to this fracture. 

1 Moore, Med.-Chir. Trans., vol. xxxiv. p. 107, 1851. 



ACETABULUM. 347 

Dr. McTyer 1 published four cases of this fracture. 

The tirst was that of a man, set. 27, on whose back a number of bricks 
had fallen while he had his right knee placed on the bank of a trench. His 
right leg was found shortened about one inch and a half, bent, and the toes 
turned a little outward. The limb could be moved without much difficulty, but 
every motion gave him pain ; motion was also attended with crepitus. On mak- 
ing extension, the limb was easily brought to the same length with the other, 
but it became shortened again immediately when the extension was discontinued. 
The symptoms, differing but little, if at all, from those which are usually present 
in a case of fracture of the neck of the femur, led to the supposition that this 
was actually the nature of the accident. Subsequently, the toes became slightly 
turned in, but this circumstance was not regarded as sufficiently distinctive to 
warrant a change in the diagnosis. Having succumbed to the injuries, the au- 
topsy revealed a fracture extending through the bottom of the right acetabulum, 
and about one inch and a half of the rim at its upper and posterior margin com- 
pletely detached, except as it was held in place by a portion of the capsular 
ligament. The head of the bone could be easily pushed upward and backward 
upon the dorsum, the fragment of the acetabular margin being moved aside, and 
swinging upon its fibrous attachment as upon a hinge, but resuming its place 
again perfectly when the head of the femur was restored to the acetabulum. 
In the second case the limb was found shortened, the knee slightly bent, and 
turned a little forward and inward, and the toes pointing to the tarsus of the 
other foot. It was thought to be a fracture also of the neck of the femur, but 
the autopsy disclosed only a fracture of the upper margin of the acetabulum. 
In the third case, seen only after death, the limb was not shortened much, but 
the toes were stretched downward, and turned slightly inward. It was supposed 
at first to be a simple dislocation, but on dissection the posterior and inferior 
margin of the acetabulum was found to be broken and displaced toward the 
coccyx, while the head of the femur rested upon the pyriformis muscle, over the 
ischiatic notch. The fourth was from the dissecting-room, and the history of the 
case is not known. A fragment of the superior and posterior margin of the ace- 
tabulum had been broken off, and had reunited slightly displaced. 2 

Several other similar examples have been established by dissection ; 3 and Dr. 
Nicholas Senn, of Milwaukee, Wisconsin, has collected a number of examples 
more or less satisfactorily demonstrated without the aid of an autopsy. 4 

The causes are -generally the same as those which produce dislocations 
of the hip, but in most instances the violence has been greater than in 
the case of dislocations. In a case reported by Miner 5 it was the result 
of a gunshot, the fragment having escaped through a fistulous opening. 

The symptoms are, first, such as indicate a dislocation, to which must 
be added crepitus and a difficulty, if not impossibility, of retaining the 
head of the femur in its place when it is reduced. The crepitus is 
sometimes discovered the moment we begin to move the limb, and this 
will aid us to distinguish it from a fracture of the neck of the femur 
accompanied with much displacement, since, in the latter case, crepitus 
is not felt usually until the extension is complete, and the fragments are 
again brought into apposition. 

Prognosis. — Some of these accidents, either from a failure to recognize 
them, or from the impossibility of maintaining the head of the femur in 
place when once it has been reduced, have resulted in a permanent dis- 

i Glasgow Med. Journ., Feb. 1830. 
• 2 McTyer, Amer. Journ. Med. Sci., vol. viii. p. 517, Aug. 1831. 

3 Maisonneuve, Ckirurg. Clin., 1863, p. 168. Sir Astley Cooper on Disloc. and Frac, 
1823, second London edition, p. 15. M. Beraud, Bulletin de la Soc. de Chir ., 1862, torn. iii. 
p. 185. Ibid., p. 226. Bigelow on Hip-joint, 1869, p. 139 et seq. Eve, British Med. Journ.. 
Jan. 24, 1880 (2 cases'. Agnew, Treat, on Surgery, vol. i. p. 929. 

4 Senn, Trans. Wisconsin State Med. Soc. 1880.* 

5 Miner, Buffalo Med. and Surg. Journ., vol. v. p. 383. 



848 



FRACTURES OF THE PELVIS. 



location of the hip and a serious maiming. In nine out of thirteen cases 
which Senn has found reported, the reduction was maintained, and in 
four it was not. The following case was recognized and reduced, but it 
was found impossible to maintain the reduction : 

A strong German laborer was crushed under a mass of iron weighing several 
tons. Drs. Sprague and Loomis, of Buffalo, were called, and found the left 
thigh dislocated upward and backward, and by the aid of six men they suc- 
ceeded in reducing it, the reduction being attended, as the gentlemen informed 
me, with a slight sensation of crepitus. The legs were then laid beside each 
other, and the knees tied together, the patient lying on his back; and now the 
two limbs appeared to be of the same length. On the second and third days the 
injured limb was examined by the same gentlemen, and there was no displace- 
ment. On the fourth day I was invited to meet these gentlemen, the patient 
having had muscular spasms during the previous night, and the thigh being 
redislocated. I found the limb shortened one inch and a half, adducted, and 
the toes turned in. We immediately applied the pulleys, and soon drew the 
trochanter down to a point apparently opposite the acetabulum, and a careful 
measurement showed that the two limbs were of the same length. The pulleys 
being removed, the leg did not draw up again, nor did the foot turn in, yet we 
had felt no sensation to indicate that the bone had slipped into its socket, nor 
had we felt crepitus. The legs and thighs were now laid over a double-inclined 
plane, and well secured. He remained in this condition three days more, during 
which time Dr. Sprague saw him each day, and found nothing disarranged. On 
the night of the seventh day the spasms returned, and in the morning the thigh 
was displaced. The next day we again applied the pulleys, but soon found that 
the bone would not remain in place one minute after the pulleys were removed. 
At this time, while moderate extension was being made at the foot by rotating 
the foot inward, we could distinctly feel a slight crepitus. A straight splint was 
applied, and as much extension made as he could conveniently bear, and in this 
condition the limb was kept several weeks. Seven years after, I found the thigh 
still displaced upon the dorsum ilii. He limped badly, but he could walk fast, 
and perform as much labor as before the accident. 

In one case mentioned by Mr. Keate, 
Fig. 192. the bone had become dislocated down- 

ward, and could be felt lying against 
the tuber ischii, and the presence of a 
"distinct grating, as of ruptured carti- 
lage," led him to conclude that the 
cartilaginous labrum of the socket was 
broken off; but as the fracture was in 
the lower margin of the socket, no diffi- 
culty was experienced in retaining the 
bone in position. 1 

Dr. Walker, of Detroit, Michigan, pre- 
sented to the Detroit Academy of Medi- 
cine a specimen of this fracture, the 
history of which was as follows : A. man, 
set. seventy-eight years, falling upon 
his hands and knees, was struck on the 
lower portion of his back by a passing 
street-car. He was taken to a hospital, 
and was found to have a dislocation 
upon the dorsum ilii. Eeduction was 
readily accomplished, and crepitus was 
recognized, but its seat not fully deter- 
mined. The patient died in a few hours 
from shock. In the autopsy the head 
of the femur was found in the socket, but it was easily displaced. The liga- 
mentum teres and a greater part of the posterior half oif the capsular ligament 




Walker's case of fracture of the acetabulum. 



1 Keate, Amer. Journ. of Med. Sci., vol. xvi. p. 225. 



SACRUM. _ 349 

were torn away, leaving a part of the anterior portion, together with the ilio- 
femoral ligament, untorn. Some of the gluteal muscles were torn from their 
femoral attachments. The greater portion of the posterior lip of the acetabu- 
lum was torn away, making an opening through which the head of the femur 
had escaped, passing between the fasciculi of the ilio-femoral ligament, and 
resting finally near the crest of the ilium. Less than one-third of the normal 
depth of the acetabulum remained to support the head of the femur when it was 
in place. 1 

Treatment. — If the diagnosis is satisfactorily made out, and upon com- 
plete reduction the femur will not remain in place, the treatment ought 
to be nearly the same as for fracture of the thigh, except that no lateral 
splints or bandages to the thigh will be necessary. If the straight position 
is chosen, the limb ought to be rotated in a direction opposite to that in 
which the acetabular margin is supposed to be broken, and kept drawn 
out to its proper length, as far as this shall be found to be practicable, 
by extending and counter-extending apparatus. A band around the 
pelvis, so adjusted as to press the head of the bone into its socket, may 
also be of service in preventing the tendency to displacement ; and in 
case the bone manifests little or none of this tendency, the hip bandage 
will probably alone be sufficient, yet even here no harm could come of 
applying the extending apparatus, secured moderately tight, simply as a 
measure of precaution. 

Dr. Bigelow recommends angular extension, effected by means of an angular 
splint, such, for example, as Nathan R. Smith's, or Hodgen's, suspended from 
the ceiling, or from some other point above the patient ; " or," he adds, " if any 
manoeuvre has reduced the bone, the limb should be retained, if possible, in the 
attitude which completed the manoeuvre." 

§ 5. Sacrum. 

Causes. — Simple fractures of the sacrum, known to be rare, 2 are occa- 
sioned either by such injuries as break, at the same time, the other bones 
of the pelvis, or by blows or falls received directly upon the sacrum. It 
may be broken at any point, and in any direction, when the fracture is 
produced by the first of this class of causes ; but if the fracture is the 
result of a fall upon the sacrum, it will generally be transverse, and below 
the sacro-iliac symphysis. The displacement in this latter class of cases 
is almost invariably the same, the coccygeal extremity being simply car- 
ried forward, yet this is seldom sufficient to interfere in any degree with 
the functions of the rectum and anus. 

In one case seen by Bermond it nearly closed the rectum. Sometimes, also, 
there is a slight lateral deviation. There is also in the Dupuytren museum, at 
Paris, a specimen in which the whole of the lower fragment is displaced a little 
forward. 

Symptoms. — The signs of this fracture are pain at the seat of injury, 
aggravated greatly in the attempts to flex or elevate the body, and espe- 
cially in the efforts at defecation ; swelling and discoloration of the soft 

1 Walker.. Detroit Lancet, July, 1879. 

2 Malgaigne has referred to eight cases; and I have not been able to find a record of any 
others. 



350 FRACTURES OF THE PELVIS. 

parts covering the sacrum ; displacement of the coccyx forward ; a'n 
angular projection at the point of fracture, with a corresponding retiring- 
angle upon the opposite side ; mobility. 

Prognosis. — Experience has shown that where the fracture of the 
sacrum is accompanied with other fractures of the pelvis, the patients 
seldom recover ; and only because so extensive an injury implies usually 
great force in the cause which produced the fractures, and, of necessity, 
greater lesions among the pelvic viscera. Simple fractures, from falls 
upon the sacrum, occurring below the sacro-iliac symphysis, are gener- 
ally followed by speedy recoveries, although the inward displacement is 
not often completely overcome. 

Treatment. — By introducing a finger into the rectum, the lower frag- 
ment can be easily pressed back to its natural position, but the difficulty 
consists in finding any means of retaining it there until bony union is 
effected. Judes succeeded to his satisfaction with a wooden cylinder, 
which he compelled the patient to wear forty-five days ; removing it 
however, every third day, in order to cleanse the rectum with an enema. 
Bermond introduced first a linen bag, which he immediately proceeded 
to fill with lint ; but during the night it became necessary to remove it, 
in order to relieve the bowels of wind and stercoraceous matter. He 
now substituted a silver canula covered with a shirt, which latter he 
filled with lint in the same manner as before. This was retained without 
much inconvenience nineteen days ; having only been removed once 
during this time. The union now seemed to be firm, and the apparatus 
was removed. Plugging the rectum in this manner may be necessary 
whenever the inward inclination of the lower fragment is found to be 
considerable, but not otherwise ; ordinarily it will be sufficient to lay the 
patient upon his back, with a firm cushion above the point of fracture, 
so as to prevent the bed from pressing in the lower fragment ; and having 
emptied his rectum thoroughly by an enema of warm water, he should 
be placed under the influence of an opiate sufficiently to restrain the 
action of the bowels for several days, or for as long a time as may be con- 
sistent with health or comfort. To the same end, also, the diet ought 
to be light and dry ; nothing should be allowed which might prove laxa- 
tive. By constipating the bowels, two ends may be gained. We shall 
prevent that frequent action of the sphincters which might tend to dis- 
turb the union ; and the hardened feces, by their accumulation in the 
rectum, may serve to press back the lower fragment of the sacrum' in a 
manner much more natural and quite as effective as any apparatus which 
can be contrived. 

Separations at the Sacro-iliac Symphysis. — A case of separation of the 
bones at the sacro-iliac symphysis, reported by Lente, was accompanied 
also with a fracture of the ilium and a dislocation of the hip. Several 
other similar examples have been reported, in some of which both of the 
sacro-iliac symphyses have been separated, or displaced Such accidents 
are the results only of great violence, and the subjects of them seldom 
recover. 

Dr. Banks, of Griffin, Ga., has reported one example of complete recovery in 
an adult male, in which the right sacro-iliac symphysis was separated "by a 
blow received upon the tuberosity of the ischium, driving the ilium up an inch 



coccyx. 351 

or more, causing complete paralysis and anaesthesia of the right leg for two or 
three weeks;" motion of the hip caused also severe pain. No attempt was made 
to reduce the bones, but union occurred, and he gradually regained the use of 
his limb. 1 In a few instances this articulation has been known to give way 
during labor, while the symphysis pubis has suffered litle or no diastasis ; and in 
these cases recovery has generally taken place. 

[Perkins, 2 surgeon to the Union Pacific Kailroad, reports a case of fracture of 
the sacrum occurring during labor. The line of the fracture was made out, after 
opening an abscess, at the sacro-iliac junction.] 

In nearly all the traumatic examples reported, the diastasis has been 
accompanied with a fracture extending parallel with the margins of the 
synchondrosis : and it is for this reason that I have preferred to con- 
sider these accidents as fractures, rather than as dislocations. 



§ 6. Coccyx. 

The bones which compose the coccyx, four in number, develop slowly, 
the third not presenting an ossific nucleus until from the tenth to the 
fifteenth years of life, and the fourth not until between the fifteenth and 
twentieth year. Subsequently the first and second become united into 
one, and later the third and fourth are united into one ; finally, the 
second and third unite, and the coccyx is complete as a single bone. At 
a late period of life, later in the female than in the male, the coccyx is 
united by bone to the sacrum. These facts render it apparent that a 
true fracture can scarcely occur until late in life ; and it seems probable. 
also, that a diastasis or dislocation will be very unlikely to occur. For 
myself, I have never met with the accident in any of its forms. Mal- 
gaigne says he has seen one example of fracture in an autopsy, in which 
case there was also a fracture of the sacrum ; and he adds that Cloquet 
had seen another in an old man, caused by a kick. 

Treatment. — In case a fracture were to occur, the treatment would be 
the same as that already described for a fracture of the lower portion of 
the sacrum. 

Dr. Mursick, of Nyack, New York, reports 3 two cases of " coccygodynia," in 
which he practised excision of the last two bones of the coccyx successfully. 
One of them was a case of fracture, with forward displacement, in a woman 
twenty-nine years old, and was caused by a fall upon the nates. Fourteen 
months after the accident she came under Dr. Mursick's observation. She was 
suffering great pain in the pelvic region, and especially in the region of the 
rectum, which was aggravated by walking, defecation, and by rising from the 
sitting position. Dr. Mursick removed the last two bones of the coccyx by 
making an incision posteriorly of two inches in length, exposing the bone 
thoroughly, and then having seized the bone with a pair of forceps, it was drawn, 
out and carefully dissected from its attachments. Severe pains in the pelvic 
region followed the operation, with retention of urine, and the wound healed 
slowly. As a result of his two operations he concludes that the operation is 
simple and easy of performance, but that the constitutional disturbance which 
ensues is out of all proportion to its magnitude. The subsequent pain is very 
severe, and lasts for several days ; and the wound heals slowly. 

1 Banks, Atlanta Med. and Surg. Journ., May, 1866. 

2 Kansas City Med. Eecord. Nov. 1888. 

3 Mursick, American Journal of the Medical Sciences, Jan. 1876, p. 122. 



352 FKACTURES OF THE FEMUR. 

Extirpation of the coccyx has been practised occasionally since the 
first differentiation of coccygodynia by Nott and Simpson, with success- 
ful results, but especially in those cases which were of traumatic origin. 
In other cases, unaccompanied with fracture or dislocation, subcutaneous 
incision of the attachments of the coccyx has proved sufficient, while in 
many cases, of purely neurotic origin, the cure has, after a time, been 
effected without resort to surgical interference. My own experience con- 
firms this latter statement. Nor can I fully appreciate the necessity or 
advantage of resection in any case of simple fracture or diastasis of this 
bone. In the case related by Mursick there is no evidence furnished 
that union had ever taken place between the second and third portions, 
and the age permits a presumption that it had not, and that it was not 
therefore in reality a fracture ; but even if it had been, what possible 
harm could come of its being rendered movable by the fracture, since if 
it were movable it could not interfere with defecation ? The coccyx is 
not without its function, and cannot without injury be lost, inasmuch as 
it serves for the attachment of muscles and ligaments, most of which are 
of importance in connection with defecation, and occlusion of the rectum. 



CHAPTER XXIX. 

FRACTURES OF THE FEMUR. 

The femur constitutes an exception to the rule that in the case of the 
long bones the lower third is most often the seat of fracture. The shaft 
of the femur is most often broken in the middle third, and generally near 
the upper end of this third ; that is to say, above its middle. 

Of 236 fractures of the femur, not including gunshot, which have been re- 
corded by me, 114 belong to the upper third, 86 to the middle third, and 36 to 
the lower third ; or, if we confine our analysis to the shaft alone, 30 belong to 
the upper third, 80 to the middle, and 36 to the lower. Hyde, in an analysis of 
322 cases, in Belle vue Hospital, states that 95 occurred in the upper third (in- 
cluding fractures of the neck), 169 in the middle third, and 38 in the lower third 
(including the condyles). In the 20 remaining cases the point of fracture is not 
stated. A summary of these tables shows that 61 fractures were in the neck, of 
which 14 are stated in the records to be intracapsular, 17 extracapsular, and 30 
undetermined ; 34 were in the upper third of the shaft, 169 in the middle third, 
and 31 in the lower, the exact point of fracture of the shaft being undetermined 
in 20 ; 7 fractures belonged to the condyles. 1 

The femur is formed from five centres of ossification : namely, one for the 
shaft, commencing at about the fifth week of foetal life ; one for the lower end, 
including the condyles, commencing at the ninth month of foetal life; one for 
the head, commencing at the end of the first year after birth ; one for the great 
trochanter, commencing during the fourth year ; and one for the lesser trochanter, 
commencing between the thirteenth and fourteenth years. None of these epiph- 

1 Hyde, Analysis of 322 cases of Fracture of the Femur, at Bellevue Hospital, from 1865 
to 1873, inclusive. Medical Record, 1875. 



NECK OF THE FEMUR. 



353 



Fig. 193. 



yses are joined to the shaft until after puberty, but consolidation is generally 
completed at the twentieth year. The order in which union occurs is the reverse 
of the order in which ossification commences, the lower epiphysis being the first 
to exhibit traces of ossification, and the last to unite. 

§ 1. Neck of the Femur. 

Surgeons have differed in their opinions as to the relative frequency 
of fractures of the neck of the femur within or without the capsule. 
This has arisen, no doubt, in part from the difficulty 
and probable inaccuracy of many of the diagnoses. 
Malgaigne finds in four large collections sixty-one in- 
tracapsular fractures, and only forty-two extracapsular ; 
according to his observations, they stand in the propor- 
tion of about three to tw T o; the intracapsular being the 
most common. On the contrary, Nelaton believes that 
extracapsular fractures are much the most common, 
and Bonnet, of Lyons, affirms that they constitute the 
immense majority. Bonnet made four dissections, and 
in each case he found the fracture extracapsular. 
This testimony, so far as it goes, is positive, but the 
number is not sufficient to establish anything more 
than a probability in favor of the greater frequency of 
extracapsular fractures. 

Eighty-four of the whole number recorded and analyzed 
by myself were fractures of neck, either intra- or extra-cap- 
sular. The youngest of these patients, excepting one case 
of supposed epiphyseal separation, was twenty-nine years, 
the oldest eighty-four; forty-five were males and thirty-nine 
females. Nearly all were simple. Forty-two were believed 
to be without the capsule, and thirty were believed to be 
within ; the remainder were undetermined. 

We have already given the number of fractures of the 
neck, both intra- and extra-capsular , reported in Dr. Hyde's 
tables. Having reference to age, 19 years was the youngest, 
and 85 the oldest ; 20 years and under presented two cases ; 
from 20 years to 30, five cases ; from 30 to 40, nine ; from Development of fe- 
40 to 50, eight ; from 50 to 60, fourteen ; from 60 to 70, fif- mur. (From Gray.) 
teen ; from 70 to 80, seven ; from 80 to 90, one. Of the 
whole number, thirty-nine were males, and twenty-two femal es ; none of the 
fractures were compound ; fourteen are recorded as of the right leg ; seventeen 
of the left; and thirty are undetermined. Fourteen were diagnosticated as 
intracapsular, and seventeen as extracapsular, thirty being undetermined. 

Clinical observations are in this case too uncertain to be made available in so 
nice a question. Cabinet specimens may have been collected for a special pur- 
pose, and this is well known to have been the fact with the celebrated Dupuy- 
tren collection, the specimens in which constitute nearly one-third of the whole 
number referred to by Malgaigne. I allude to the effort which was made while 
the controversy was pending between Dupuytren and Sir Astley Cooper as to 
the probability of bony union in intracapsular fractures, to accumulate cabinet 
specimens of this fracture ; and which effort extended itself, no doubt, both to 
London and Dublin, from which two latter sources Malgaigne has gathered the 
remainder of his figures. In Mutter's collection there are three examples of 
intracapsular fracture, to seven extracapsular. Mussey, of Cincinnati, has in 
his cabinet twelve examples of fractures of the neck of the femur without the 
capsule, and only ten within. We ought, therefore, to regard the question of 
relative frequency as still undetermined. Nevertheless, it is my opinion that 
the extracapsular fracture is very much the most frequent. 

23 




354 



fractures of the femur. 



The predisposing causes of this accident to the neck play an important 
part in fractures whether within or without the capsule ; indeed, expe- 



Fig. 194. 



Fig. 195. 




Intracapsular fracture of the neck. 

rience has shown that without the 
concurrence of those pathological 
changes which usually accompany old 
age, these fractures can scarcely occur. 
Dr. Merkel considers the fragility of 
the neck, within the capsule, in old 
persons, due to the absorption of that 
process of the cortical substance which 
arises from about the level of the tro- 
chanter minor, and ends close under 
the head of the bone, at the anterior 
part of the neck ; thus occupying the 
situation where the greatest pressure is made in the erect position. This 
process he calls the " calcar femorale." In newly-born children it is 
absent ; it appears when they begin to walk, attains its greatest develop- 
ment in middle age, and completely disappears in old persons. 1 




Horizontal section of neck of femur. 
(From Bigelow.) 



(a) Intracapsular Fractures. 

Causes. — The position of the neck, and the great thickness of the 
muscular coverings, render its fracture from a direct blow a very rare 
circumstance ; indeed, it can only happen as the result of gunshot acci- 
dents, or other similar penetrating injuries. It is broken, therefore, 
usually by indirect blows, such as a fall upon the bottom of the foot, 
upon the knee, or upon the trochanter major; or by muscular action 
alone, as has sometimes happened with very old people, who, in walking 
across the floor, have tripped upon the carpet, breaking the bone in the 
effort to save themselves. 



1 Merkel, Amer. Journ. Med. Sci.. Jan. 1874. 



NECK OF THE FEMUR, 



355 



We must not always infer, however, because the patient has tripped, that the 
bone was broken by muscular action ; since it is quite as likely that the fall, con- 
sequent upon the tripping, has occasioned the fracture ; and we ought in such 
cases to make a careful examination of the hip over the trochanter to ascertain 
whether it has been bruised, and to ask the patient as to the manner of the fall. 
Eodet has attempted to show by a series of experiments that when the person 
has fallen upon the foot or knee, the fracture will be intracapsular and oblique ; 
that if the front of the trochanter receives the blow, the fracture will be intra- 
capsular also, but transverse ; if the back of the trochanter is struck, the fracture 
will be partly intra- and partly extra-capsular ; and if the person falls directly 
upon the side, or receives the blow fairly upon the outer side of the trochanter, 
the fracture will be entirely without the capsule. 1 Without giving my unquali- 
fied assent to the propositions, I admit their general accuracy ; and especially 
has my experience led me to believe that falls upon the feet or knees in most 
cases produce intracapsular fractures, and that falls upon the outside of the hip, 
or upon the great trochanter, generally produce extracapsular fractures. There 
are, however, frequent exceptions to this latter proposition. Especially have 



Fig. 196. 



Fig. 197. 





Transverse intracapsular fracture. 



Intracapsular fracture caused by a fall 
upon the trochanter. 



I observed that in persons over fifty years of age, or somewhat advanced in life, 
a fall upon the trochanter has caused an intracapsular fracture. The following- 
case, verified by an autopsy, is conclusive : A man, seventy-five years of age, was 
received at Bellevue. He stated that on the same day he had slipped and fallen 
upon the sidewalk, striking with great force upon the trochanter. The house 
surgeon examined the limb immediately on admission, and diagnosticated an 
intracapsular fracture. I saw him during the day and confirmed the diagnosis. 
He was feeble, but not suffering much, apparently, from shock or from pain. 
On the following morning he was found to be sinking, and he died before night. 
The accompanying illustration (Fig. 196), taken from the specimen, shows that 
the fracture was close to the head, and entirely intracapsular. It was not im- 
pacted, and no absorption of the neck had taken place. 

Pathology. — A partial fracture, or a fissure of the neck of the femur, 
is possible, yet its occurrence must be regarded as an exceedingly rare 
and, we may say, improbable event. It is much more common to meet 



L'Experience, March 14, 1844. 



356 



'FRACTURES OF THE FEMUR. 



with examples of complete fractures of the neck both within and without 
the capsule, unaccompanied with a rupture of either the periosteum or 
the reflected capsule. 

Such was the fact in eight cases examined by Colles ; in three of which, how- 
ever, he believed the fracture not to have been complete, but Robert Smith 
thinks they were all of them examples of complete fracture. 1 Stanley has also 
related a case of complete separation of the bone unaccompanied with laceration 
or injury of either the periosteum or capsular ligament. This was in the person 
of a man aged sixty years, who had been knocked down in the street. On being 
admitted into St. Bartholomew's Hospital, shortly after the injury, he com- 
plained of pain in the hip, but there was neither shortening nor eversion of the 
limb, and its several motions could be executed with freedom and power. A 
fracture was not suspected ; but five weeks after this he died of inflammation of 
the bowels. The dissection showed a fracture extending through the neck, 
accompanied with a slight bloody effusion, but no displacement of the fragments 
or laceration of the soft parts. 2 

In other examples the bone is not only broken, but displaced to such 
an extent that the capsule is completely torn in two. But in a large 
majority of cases both the capsule and the periosteum are only partially 
torn asunder. The intracapsular fracture is generally somewhat oblique, 
and its direction is usually from above downward, and from within out- 
ward. Sometimes its direction is such as to include a portion of the 



Fig. 198. 



Fig. 199. 





Impacted intracapsular fracture. 
(Smith.) 



head ; occasionally it is quite 
transverse. Occasionally the in- 
tracapsular fracture is impacted. 
In one example of an old fracture 
I have seen the ends dovetailed 
upon each other, the fracture 
having a double obliquity, and 
not admitting of displacement. 
There may occur also another species of impaction, the lower portion of 
the neck entering the cancellous structure of the head, while its upper 



Impacted fracture within the capsule. 
(From Bigelow.) 



1 Colles, Dublin Hosp. Rep., vol. ii. p. 339. 

2 Stanley, Med.-Chir. Trans., vol. xiii. 



NECK OF THE FEMUR. 357 

portion rides upon the articular surface (Fig. 198) ; or the impaction 
may occur without any degree of either upward or lateral displacement. 
Separation of the epiphysis which completes the head of the femur 
may occur in young persons. 1 

Mr. South relates a case in a boy ten years of age, who had fallen out of a 
first-floor window upon his left hip. The limb was slightly turned out, but 
scarcely at all shortened. The thigh could be readily moved in any direction 
without much pain, but on bending the limb and rotating it outward, a very 
distinct dummy sensation was frequently felt, apparently within the joint, as if 
one articular surface had slipped off another. This was regarded by Mr. South 
and Mr. Green as an example of epiphyseal separation. 2 

Dr. Post mentioned a case which he had seen in a girl sixteen years old, who, 
in taking a slight step with a child in her arms, made a false movement, and 
.feeling something give way, she was obliged to lean against a wall. The next 
day the affected limb was one inch shorter than the opposite one, movable, the 
toes turned outward, no swelling, some slight pain at the upper part of the thigh. 
The trochanter major moved with the shaft. There was also crepitus. From 
the age of the patient, and the slight amount of violence by which the injury 
was produced, Dr. Post thought a separation of the epiphysis of the head had 
taken place. The extending apparatus was applied, but the limb remained from 
a quarter to half an inch shorter than its fellow. 3 

A. L., set. 15, fell from the fourth story. I found his right thigh shortened 
three-quarters of an inch, and slightly abducted ; toes everted. There was a 
feeble crepitus in the vicinity of the joint, unlike the crepitus of broken bone. 
I believe it to have been a separation of the upper epiphysis. 

Only one case has been established by an autopsy. The subject of this acci- 
dent, who was fifteen years old, had been run over by a wagon. The limb was 
shortened and everted. The patient was unable to move the limb. He died in 
a few hours. There was found in the autopsic examination, complete separation 
of the epiphysis, which was attached to the neck by a strip of periosteum two 
millimetres in breadth. The capsule was torn at its inner portion. 4 

Dr. Stetter 5 has reported a case observed in a child fourteen years old, and 
supposed by Professor Schonborn, of Konigsberg, to be caused by muscular 
action. The lad having slipped, threw himself backward to save himself, and 
fell on his left side. He experienced violent pain on the right side, and was 
unabre to run. The right limb was found shortened three centimetres, and 
strongly everted. No crepitus could be detected, but there was swelling in the 
region of the right trochanter, and the motion of the limb produced by flexion 
caused intense pain. 

Symptoms. — We have as yet no means of determining absolutely the 
symptoms of epiphyseal separation. In true fractures the limb will be 
shortened or not, according as the fragments are impacted or have be- 
come displaced in the direction of the axis of the shaft of the femur. If 
impacted, the broken ends frequently remain in contact for several hours 
or days, or until the gradual contraction of the muscles or the weight of 
the body upon the limb occasions a separation, and that consequently 
there is often at first no appreciable or actual shortening of the limb. 
To determine, however, its existence, it is not sufficient to lay the patient 
upon his back and place the limbs beside each other ; we ought also to 
measure carefully with a tape-line from the pelvis to the leg or foot, and 
from various other points, until we have placed this question beyond a 

1 Liston, Elements of Surgery, Phila., 18ST. 

2 South, note to Ckelius's Surgery, vol. i. p. 619. 

3 Post. New York Journ. Med., vol. iii. p. 190, Julv. 1840. 

4 Bullet, cle la Societe Anat., 1867, p. 283. 

5 G Stetter, Centralblatt far Chir.. 1ST7. No. 36, S. 561. 



358 FRACTURES OF THE FEMUR. 

doubt. If shortening occurs, it may vary from one- quarter of an inch 
to two inches, or even more ; but this extreme shortening is not reached 
usually, except after the lapse of several weeks or months, when the liga- 
ments have gradually given way under the weight of the body in walk- 
ing, or not until the neck has undergone a partial or almost complete 
absorption. In a large majority of cases the shortening does not at first 
exceed one inch. 

Sir Astley Cooper has stated that a shortening to this degree may occur at 
once ; but Boyer, Earle, and others, doubt the accuracy of this opinion, and 
Robert Smith declares that he does not think the capsule would admit of such 
an amount of immediate displacement, unless it were extensively torn, an occur- 
rence which he thinks very rare indeed. 

Crepitus, unlike shortening, is generally absent when the displacement 
of the fragments is complete ; but under no circumstances is it easily 
developed. When the fragments remain in apposition, and the femur is 
rotated for the purpose of moving the broken surfaces upon each other, 
the small acetabular fragment, resting in a smooth cup-like socket, and 
holding upon the opposite fragment by denticulations or by the untorn 
periosteum, or capsule, glides about in obedience to the motions of this 
latter, and no crepitus can be produced. Nor is the difficulty rendered 
less by pressing firmly upon the trochanter, as some surgeons have 
recommended, since, while this pressure tends, no doubt, to fasten the 
upper fragment in the acetabulum, it tends much more to fasten the 
broken ends together, and thus defeats the purpose in view. When, on 
the other hand, the fragments have become completely separated, it is 
almost impossible to bring them again into contact. The limb may, 
perhaps, be easily brought down to the same length with the other, but 
it must by no means be inferred that, consequently, the broken ends are 
in apposition. It is almost certain, indeed, that in its progress downward 
the trochanteric fragment has caught upon the acetabular fragment, and 
pushed its floating and broken extremity downward before it. Under 
these circumstances, the discovery of a crepitus must be accidental and 
is scarcely to be looked for. Sometimes, however, we may recognize a 
sound not unlike crepitus, but less harsh, produced by the friction of the 
trochanteric fragment against the rim of the acetabulum or dorsum of the 
ilium. 

One thing we ought never to forget, namely, that by extraordinary efforts to 
obtain a crepitus we may lacerate the capsule or produce a displacement of the 
fragments which we never can remedy, and which, without such unwarrantable 
manipulation, might never have occurred. 

[The caution here given to avoid extreme efforts to obtain crepitus lest an 
impacted fracture be separated should be emphasized. This is especially true 
of those cases where impaction is suspected. If there is but slight shortening, 
the foot everted, great tenderness and pain at the hip, and the patient has 
fallen upon the trochanter, it is better to assume that there is a fracture with 
impaction, and treat it accordingly, than to use any force to make the diagnosis 
certain. Two cases which have come under my observation have led me to com- 
mence at once the treatment of such cases as impacted fractures. The first case 
was an old lady who fell from a rail car upon the left hip. There was half an 
inch shortening, slight eversion of the foot, and great pain at the hip on moving 
the limb. She was seen by Dr. Parker and Dr. Van Buren, and as there was 
no crepitus, the diagnosis was a bruise of the hip. Two weeks after the injury, 



NECK OF THE FEMUR. 359 

on placing the leg over the edge of the bed, she felt the bone separate at the 
hip. On examination soon after, the shortening was two inches and the crepitus 
very pronounced. Union never occurred. The second case was seen in Bellevue 
Hospital, in consultation with the late Dr. Lidell. The patient was a woman, 
set. 50, who had fallen on the hip. There was half an inch shortening, pain at 
the hip, but no crepitus on moderate movements of the limb. An anaesthetic 
was given and more determined efforts made to obtain crepitus. During these 
free movements the fragments separated, with abundant crepitus. Union was 
subsequently obtained.] 

Eversion of the foot is almost uniformly present in some degree, taking 
place immediately or more gradually, in proportion as the fragments 
become displaced, and the external rotators contract. The opposite 
condition, or an inversion of the foot, is occasionally present, and some- 
times also the foot is neither turned in nor out, but the toes point directly 
forward. 

In sixty, cases of fracture of the neck seen by Cloquet the foot was never 
turned in, and Boyer never met with such an example in all of his immense 
experience; but Langstaff, Guthrie, Stanley, Cruveilhier, Bigelow, Conklin, 1 
have each seen one example, and Eobert Smith has seen two. 2 I have myself 
seen one. 

The explanation of the fact that the foot is usually everted is not diffi- 
cult. In the case of an intracapsular fracture it is probably clue, first, 
to the relative friability of the laminated or cortical structure on the pos- 
terior aspect of the neck, in consequence of which this portion gives way 
more readily than the cortical structure on the anterior aspect ; second, 
to the natural form and position of the foot and leg, which incline them 
to fall outward by their own weight ; and, third, to the powerful action of 
the external rotators, which are so feebly antagonized upon the opposite 
side. In the case of an extracapsular impacted fracture, in addition to 
the second and third causes assigned as influencing the position of the 
limb in intracapsular fractures, there are other special causes. The cor- 
tical lamina on the posterior aspect of the neck, everywhere more frail 
than upon the anterior aspect, becomes greatly weakened as it approaches 
the trochanter by dividing itself into two laminae, one of which penetrates 
toward the centre of the bone, and the other, the thinner of the two, 
being scarcely thicker than a sheet of paper, forming the wall of the bone 
as it becomes continuous with the trochanter. This delicate papery wall 
easily gives way under the application of force, while the anterior wall 
yields only partially, constituting thus a sort of hinge upon which the 
rotation of the thigh is performed. It is probable, also, as suggested by 
M. Robert, that the angle at which the external surface of the trochanter 
unites with the neck increases the tendency to fracture and impaction 
posteriorly. An explanation of the fact already stated, that in rare and 
exceptional cases the limb is inverted or the toes are permitted to point 
directly forward, has been thought to be more difficult. 

Dr. Bigelow has had an opportunity of examining a specimen taken from an 
old woman in the dissecting-room, and he concludes that the inversion was due 
to the extent of the comminution, which had separated the walls of the shaft so 

1 W, J. Conklin, Ohio, Columbus Med. Journ., Nov. 1882. 

- Robert Smith, op. cit., p. 25. A. Cooper, by B. Cooper, op. eit., p. 151, note. 



360 



FRACTURES OF THE FEMUR. 



as to receive in the interval the whole neck, instead of the posterior wall only, 
as commonly occurs. Dr. Eobert Smith, of Dublin, cites a similar case verified 
by the autopsy ; and Dr. Bigelow remarks that the specimen numbered 248 in 
the Mutter museum, at Philadelphia, presents the same kind of impaction with- 
out either inversion or eversion. 

Diagnosis.- — Fracture of the neck within the capsule is not usually 
attended with much pain when the patient is at rest, but any attempt to 
move the limb produces intense suffering, and especially when an attempt 
is made to rotate the limb inward, or to carry it upward and inward. 
Occasionally, also, during the first few days or hours after the fracture, 
a spasmodic action of the muscles compels the patient to cry out from the 
severity of the pain which it produces. At first the sufferer is unable to 
indicate clearly the seat of this pain, or, perhaps, it is diffused and un- 

Fig. 200. 




Extracapsular fracture, with inversion. (From Bigelow.) 



certain in its position ; but after a time he is able to refer it chiefly to the 
region of the groin, opposite the neck of the bone, or to near the point 
of attachment of the psoas magnus and jliacus internus. There is also 
usually in this region a great degree of tenderness and an unusual fulness. 
If now the limb be seized, and extension gradually but firmly applied, 
it will be soon made of the same length with the opposite thigh ; but, the 
moment the extension is discontinued, the shortening and eversion will 
recur, accompanied with pain, and perhaps crepitus. The trochanter 
major is less prominent than upon the opposite side, and if eversion of 
the limb exists, the trochanter may be felt indistinctly upward and back- 
ward from its usual position. The patient having been placed under the 



NECK OF THE FEMUR. 361 

influence of an anaesthetic, we may prosecute the investigation still 
further, and by rotating the limb inward and outward as far as it will 
admit, we shall notice that the trochanter describes the arc of a smaller 
circle than in the opposite limb, or that the length of its radius has been 
shortened. This amount of manipulation is, however, often injurious, 
and seldom proper. The patient is generally unable to move his limb, 
or to bear the least weight upon it ; but many examples are on record of 
persons who walked some distance after the fracture had taken place, 
the capsule, and perhaps also the periosteum, not being torn, and conse- 
quently the fragments not being displaced ; or, possibly, it was at first 
an impacted fracture. 

Mrs. E., of Brooklyn, was ascending a flight of steps when her lirnb suddenly 
gave way under her, in consequence of an intracapsular fracture. Mrs. E. was 
seventy-eight years of age, large, and rather fat. For several years she had suf- 
fered from rheumatism of the right leg, which compelled her, in walking, to bear 
her weight chiefly on the left, and it was this limb which gave way. She was 
assisted to her feet, and with the aid of her daughter ascended another flight of 
steps, bearing some weight on the broken leg. On the following day she got out 
of bed alone, and, unaided, walked a few steps, moving her limb very carefully. 
On the same day I saw her and found her in bed, the limb shortened half an 
inch and slightly everted. The head of the femur moved with the trochanter 
and without causing crepitus or pain. There was very little tenderness about 
the hip or groin; no swelling, and only a heavy, dull aching pain in the limb. 
The age, the manner of the accident, and the shortening of the limb were the 
only signs of fracture, but these were sufficient. 

[McTyer 1 reported the case of a woman who, after a fall upon her side, con- 
tinued to walk for three months, with but slight lameness ; an abscess formed 
which communicated with the hip-joint; she died soon after, and the neck of 
the femur was found fractured.] 

[Hunt, of Philadelphia, had a patient who, after being struck across the thigh, 
came to the hospital on the following day, walking more than a furlong. He 
died on the twenty-seventh day, an abscess having formed, when the neck of 
the femur was found broken near the head. 2 ] 

Finally, after having examined the patient as well as we are able to 
do, in the recumbent posture, if any doubt remains, and it is found prac- 
ticable for the patient to be elevated upon his sound foot, this should be 
done. The broken limb can now be examined thoroughly on all sides, 
and a more accurate opinion formed of the amount of shortening and 
eversion. It will be especially noticed that if the weight of the body is 
allowed to rest upon the limb, in most cases it produces insupportable 
pain. 

M. Maisonneuve has lately suggested and practised the following method of 
diagnosis in certain doubtful cases : Lay the patient flat on his belly, and then 
bring the suspected thigh into extreme extension backward. If it is not broken, 
the neck will strike against the posterior lip of the acetabulum and the progress 
of the thigh in this direction will be arrested. If it is broken, it can be carried 
backward much farther. s Of this method as a means of diagnosis, it seems 
proper to say that, if the fragments have slid past each other and the limb is 
shortened, it is unnecessary ; and if they are still in apposition, it will be pretty 
certain to cause displacement, and thus do irreparable mischief. 

1 Glasgow Med. Journ., 1881 - Phila. Med. Times, Oct. 26, 1872. 

3 Maisonneuve. Traite du Diagnos. Malad. Chir., par Em. Foucher, torn. i. prem. 2)art. 
p. 287. 



362 FRACTURES OF THE FEMUR. 

[We must again repeat that efforts to determine positively the existence of 
fracture in doubtful cases of injury to the hip, and especially by the production 
of crepitus, cannot be too strongly deprecated. Shortening and eversion are the 
two most reliable symptoms, both of which can be determined without manipu- 
lating the limb. If the shortening is one to two inches, with eversion or inver- 
sion, a complete fracture of the neck — the injury being to the hip — is undoubted, 
if there has been no previous injury or disease of the limbs. Shortening to the 
extent of one-half to one inch, with slight eversion, indicates fracture of the neck 
in healthy limbs. Shortening of less than half an inch, with eversion and other 
symptoms, as pain in the hip, after direct injury to the part, are sufficiently 
suspicious to warrant a surgeon in considering the case one of fracture. Wight, 1 
of Brooklyn, says : "In a suspected fracture of the neck of the femur I examine 
all of the witnesses of fracture except crepitus, and if these witnesses agree sub- 
stantially, I pronounce a verdict in favor of fracture of the neck of the femur ; 
and if there is a doubt as to the correctness of such a verdict, I give the patient 
the benefit of that doubt by treating the case as if there was a fracture of the 
neck of the femur." Post, 2 of New York, remarks: "The surgeon, in his 
anxiety to obtain a perfect diagnosis, moves the limb freely in all directions ; 
he overcomes the impaction, rupturing the cervical ligament, demonstrates 
beyond all doubt the existence of fracture, and effectually destroys all hope of 
reunion. For my part, I prefer an imperfect diagnosis for the surgeon and a 
perfect limb for the patient, rather than a perfect diagnosis for the surgeon and 
a useless limb for the patient."] 

Prognosis. — The question of bony union after a complete fracture of 
the neck of the femur within the capsule has occupied the attention of 
the ablest surgeons and pathologists for a long period ; and while great 
differences of opinion have been expressed as to the probability of the 
occurrence, and as to the value of the testimony on the one side or the 
other, very few have ventured to deny its possibility. 

Among these latter are found, however, the distinguished names of Cruveil- 
hier, Colles, Lonsdale, and Bransby Cooper. It has been repeatedly affirmed, 
also, that Sir Astley Cooper taught the same doctrine, but with how much show 
of reason, the following paragraphs from his own pen will determine: 

" I find in a report of the Baron Dupuytren's lecture that he attributes to me 
the opinion that fractures of the neck of the thigh-bone, within the capsular 
ligament, not only 'never unite, but that it is impossible that they should unite 
by bone.' It is quite true that, as a general principle, I believe that those frac- 
tures unite by ligament, and not by bone, as do those of the patella and olecra- 
non. But I deny that I have ever stated the impossibility of their ossific union ; 
on the contrary, I have given the reason why they may occasionally unite by 
bone. The following are my words : 'To deny the possibility of their union, 
and to maintain that no exception to this general rule may take place, would be 
presumptuous, ' " 3 etc. 

Sir Astley, then, so far from denying, frankly admitted the possibility of bony 
union when the neck was broken within the capsule. The true point in dispute 
was, whether certain cabinet specimens were actually examples of complete frac- 
tures, wholly within the capsule, united by bone. Some of them, Sir Astley 
thought, were only examples of chronic rheumatic arthritis, or of interstitial 
and progressive absorption. Some were partial rather than complete fractures ; 
others were partly within and partly without the capsule. The truth is, how- 
ever, that although the claim has been set up and stoutly maintained for more 
than thirty cabinet specimens, in one part of the world or another, a majority of 
these, including several whose claims were urged upon Sir Astley, have been at 
length declared by all parties unsatisfactory, or absolutely fictitious, and only a 
fraction of the whole number continue to be mentioned by any surgical writer 

i Proceedings Med. Soc. of the County of Kings, 1881. 

2 Trans. Amer. Surg. Assoc., 1883. 3 Lond. Med. Gaz., 1834. 



NECK OF THE FEMUR 



363 



Fig. 201 



as probable examples. 1 Robert Smith reduces the number to seven, but Mal- 
gaigne recognizes only three. Six of the nineteen cases which I have enume- 
rated are declared by him to resemble much more rhachitic alterations of the 
neck than true fractures. 

On this side of the Atlantic, the number of specimens for which the honor is 
claimed is nearly equal to the original number in Europe ; but they have not 
yet, all of them, been subjected to the same 
sifting process as their foreign congeners ; and 
it remains to be seen how many of them will 
come successfully out of a similar fifty years' 
contest. Dr. Packard, of Philadelphia, has 
published an excellent critical notice of most 
or all of the published cases, and suggests that 
they all admit of the following explanation : 
The fractures were actually extracapsular ; 
but, after union took place, that portion of the 
neck attached to the head underwent absorp- 
tion, until the head was brought into contact 
with the trochanters. 

I have also in my own cabinet a femur of no 
inconsiderable pretensions (Fig. 201), belong- 
ing clearly to that class of specimens recog- 
nized by Robert Smith. Its neck is greatly 
shortened, and this surgeon would regard it, I 
ihink, as an impacted intracapsular fracture, 
but its claim would be promptly denied by 
Malgaigne, on account of the absorption and 
distortion of its neck. 

Dr. George K. Smith, of the Long Island 
College Hospital, has made a most valuable 
contribution to our knowledge of the anatomy 
and pathology of the hip-joint, which will ex- 
plain in a great measure the discrepancies of 
opinion which at present exist among surgeons 
as to the character of certain specimens, and may hereafter enable us to decide 
with more accuracy, and may lead to a better agreement of opinion. 

His observations prove that anatomists have not hitherto correctly described 
the attachment of the capsule ; that the capsule is seldom, if ever, attached at 
the same point in different persons, while it is as uniformly found attach ed at the 
same point in the opposite femurs of the same person. In order, therefore, to 
determine whether the line of fracture in any given specimen was without or 
within the capsule, we must always compare the fractured bone with its congener, 
and not with the femur of another person. 

He has further shown that after a fracture, and the consequent absorption ot 
the neck, the normal position of the capsule is almost constantly changed ; so 
that its present attachment does not declare what were the points of its attach- 
ment before the fracture occurred ; and, finally, that the absorption proceeds 
unequally and irregularly, yet with great rapidity, in the two fragments ; and as 




Vertical section of Mrs. Wakelee' 
femur, acetabulum, and capsule. 



i The following European surgeons have claimed to have in their possession, each, one 
example : Langstaff (Med.-Chir. Trans., vol. xiii., 1827); Brulatour, Ibid., vol. xiii., 1827) ; 
Stanley (Ibid., xviii.),- Swan (Swan on Diseases of Nerves, p. 304); Adams (Todd's 
Cyclop., p. 813),- Jones (Med.-Chir. Trans., vol. xxiv.); Chorley (Amesbury on Frac, p. 
125) ; Field (Ibid., p. 128) j Soemmering (Chelius's Surgery by South, vol. i. p. 621) ; South 
(Ibid., p. 621). South also mentions another example as being in the museum of St. Bar- 
tholomew's Hospital. This is probably Jones's case, which Eobert Smith says is preserved 
in this museum, and which has already been enumerated. Bryant (Memphis Med. Eec, 
vol. vi. p. 108, from British Med. Journ., March 14) : Fawcington (Amer. Journ. Med. Sci., 
vol. xv. p. 534, from London Med. Gaz., Aug. 16, 1834) ; Harris (Ibid., vol. xviii. p. 246, 
from Dublin Journ., Sept. 1835). B,obert Hamilton says that Prof Tilanus showed him 
three specimens in the museum of the Hospital of St. Peter, at Amsterdam (Ibid., vol. 
xxxi. 470, from Lond. Med. Gaz., Jan. 6, 1843). Malgaigne says there are three specimens 
in the Dupuytren museum which have been described with the same interpretation. The 
whole number claimed by transatlantic surgeons is therefore nineteen. 



364 



FRACTURES OF THE FEMUR, 



the bony union, if it ever takes place, probably occurs subsequent to the arrest 
of the absorption, the line of union cannot in itself alone determine whether the 
fracture was near the head or near the trochanters. 1 

[Bryant, of London, has illustrated these changes. (Figs. 202, 203.) ] 



Fig. 202. 



Fig. 203. 





Fig. 204. 



Absorption of the neck after fracture. (Bryant.) 

It seems to me probable that, under certain favorable circumstances, 
this union will occur ; these favorable circumstances have relation to 
several conditions, such as age, health, degree of separation of the frag- 
ments, whether impacted or not, laceration of the periosteum and capsule, 

treatment, etc. But such a combination 
of circumstances is probably exceedingly 
rare ; and, what is more unfortunate, if 
they exist, the fracture is not likely to 
be recognized, and the surgeon will fail 
to avail himself of those advantageous 
coincidences which might, if understood 
and properly treated, secure a bony 
union. There will not be wanting, how- 
ever, examples in which surgeons will 
believe or affirm that they have recog- 
nized the fracture and wrought the cure. 
These fractures may be confounded 
with several pathological conditions, but 
it will be sufficient to allude to what has 
been variously termed "morbus coxse 
senilis " (Robert Smith) ; " chronic rheu- 
matic arthritis" (Adams); "interstitial 
absorption of the neck of the " thigh- 
bone " (B, Bell); "rheumatic gout" 
(Fuller); and by others " dry arthritis" "interstitial and progressive 
absorption." We shall, perhaps, find a partial explanation of this diver- 
sity and frequency in one single circumstance, namely, the peculiar ana- 




Section of a sound adult femur. 



} George K. Smith, Insertion of the capsular ligament of the hip-joint, and its relation 
to intracapsular fracture. Medical and Surgical Re]:>orter, Philadelphia, 1862. 



NECK OF THE FEMUR 



365 



tomical structure of the neck. The neck of the femur stands nearly at 
a right angle with the shaft, or at an angle so great as that the weight 
of the body, even in health, has the effect to depress gradually the head 
below the top of the trochanter major, and to diminish its length. This 
is seen constantly in the striking change of form which occurs between 
childhood and old age. Now, if from any cause whatever, such as a blow 
upon the trochanter or upon the foot, the neck or head is made to suffer ; 
and inflammation, or, perhaps, only a slight degree of increased action in 
the absorbents, ensues, resulting in an equally slight softening of the 
bony tissue, these pathological circumstances may end, sooner or later, 
in a striking change of form in the neck or head. But it is not neces- 
sary to suppose an external injury to explain the occurrence of this 
inflammation, and consequent softening of the bone ; a scrofulous, or 
rickety, or tuberculous constitution may occasion it, and we see no reason 
why these conditions are not as likely to lead to a change of form here 
as in the bones of the leg or of the spine. A change of form in the head 
may be the result of an ulceration of the cartilage ; and a change of 
form in the neck, of ulceration of the neck. Among other causes, also, 
" chronic rheumatic arthritis " may operate in a large proportion of those 
examples which belong to advanced life. It is plain, from the direction 
which the deviation of the head and neck usually takes, that pressure 
performs an important part in the causation. 

Fig. 205. 




Chronic rheumatic arthritis. (Miller.) 

From these various causes, operating in these diverse ways, we shall 
have the different deformities enumerated and described by surgical 
writers. The head flattened, irregularly spread out, depressed, and 
polished ; the neck shortened and irregularly thickened and expanded ; 
the trochanter major rotated outward and drawn upward ; sinuous 
chasms traversing the neck, produced by ulceration ; and finally, short- 



366 FRACTURES OF THE FEMUR. 

ening of the neck, by a true interstitial absorption, and with little or no 
increase in its breadth, the trochanter major also being rotated outward. 
It would be strange, moreover, if the interior of these bones did not 
present some changes in structure, such as have been frequently ob- 
served, namely, an irregular expansion or condensation of the cellular 
tissue, and which latter might easily be supposed, by one who was inat- 
tentive to all of these circumstances, to indicate the line of an imaginary 
fracture. 

The chief difficulties in the way of union by bone within the capsule 
are as follows : The persons to whom the accident occurs are generally 
advanced in life, and consequently the process of repair is feeble and 
slow. The head of the bone receives its supply of blood chiefly through 
the neck and reflected capsule, and, when both are severed, the small 
amount furnished by the round ligament is found to be insufficient. 
When the fragments are once displaced, it is difficult, as I have already 
explained, if not impossible, to replace them. The direction of the frac- 
ture is generally such, that the ends of the fragments do not properly 
support and sustain each other when they are in apposition. The frac- 
ture is at a point where the most powerful muscles of the body, acting 
with great advantage, tend to displace the broken ends. Aged persons, 
who are chiefly the subjects of this accident, do not bear w r ell the neces- 
sary confinement, and especially as the union requires generally a longer 
time than the union of any other fracture ; so that a persistence in the 
attempt to confine the patient the requisite time often causes death. In 
all cases in which any degree of displacement exists, except it be in the 
direction of impaction, the ends of the broken fragments are constantly 
bathed with the synovial fluid, which must be increased by the inflam- 
mation resulting from the fracture. Consequently, whatever reparative 
bony material is furnished by the broken surfaces must be lost, rendering 
bony union, or even fibrous union from this source impossible. Lastly, 
there is never found in these intracapsular fractures anything like pro- 
visional callus ; and whatever useful purpose it may serve in other frac- 
tures, it certainly renders no aid here. 

The most common results of this fracture are as follows : The bones, 
more or less displaced, undergo various changes. The acetabular frag- 
ment is generally rapidly absorbed as far as the head ; and occasionally 
a considerable portion of this latter disappears also ; while the trochanteric 
fragment appears rather as if it had been flattened out by pressure and 
friction, it having gained as much generally in thickness as it has lost in 
length. To this observation, however, there will be found many excep- 
tions. Sometimes the trochanteric fragment forms an open, shallow 
socket, into which the acetabular fragment is received ; or its extremity 
may be irregularly convex and concave, to correspond with an exactly 
opposite condition of the acetabular fragment. (Fig- 206.) 

Ordinarily the two fragments move upon each other, without the inter- 
vention of any substance ; but often they become united, more or less 
completely, by fibrous bands (Fig. 207), which bands may be short or 
long, according to the amount of motion which has been maintained 
between the fragments while they are forming, or to the degree of separa- 
tion which exists. The capsular ligaments are usually considerably 



NECK OF THE FEMUR. 



367 



thickened, and elongated in certain directions, and not unfrequently pene- 
trated by spicula of bone. They are also found sometimes attached by 
firm bands to the acetabular fragment. 



Fig. 206. 



Fig. 201 





Intracapsular fracture. Ununited. Op- 
posite surfaces irregularly convex and con- 
cave, and polished ; moving slightly upon 
each other. (From a specimen in the pos- 
session of Dr. Josiah Crosby.) 



Mayo's specimen. United by ligament. 
Patient lived nine months after the accident. 
The trochanter minor arrested the descent 
of the head. (From Sir. A. Cooper.) 



A permanent shortening is the invariable result of this accident ; and 
a few succumb rapidly to the injury, perishing from a low, irritative 
fever, or from gradual exhaustion, within a month or two from the time 
of its occurrence. 

Says Kobert Smith : " Our prognosis, in cases of fracture of the neck of the 
femur, must always be unfavorable. In many instances the injury soon proves 
fatal, and in all the functions of the limb are forever impaired ; no matter 
whether the fracture has taken place within 01 external to the capsule — whether 
it has united by ligament or bone — shortening of the limb and lameness are the 
inevitable results." 

Dr. Hyde, of this city, has made a very careful examination of twenty cases 
of fracture of the neck of the femur, after several years from the date of the 
fracture. Thirteen of these had been diagnosticated as intracapsular, and seven 
as extracapsular. All were shortened ; the shortening ranging from three-eighths 
of an inch to two and a quarter inches in the intracapsular fractures ; and from 
one-quarter to one and a half inches in the extracapsular. Some of the cases 
had never been treated by apparatus of any kind, and it was observed that, 
omitting one case in which the contracted position of the limb did not permit 
an accurate measurement, the average shortening was one and three-eighths of 
an inch ; while in those which had been treated as fractures, the average shorten- 
ing was about one inch. All, or nearly all of them, were still suffering with 
more or less pain and stiffness about the joint, and walked with a manifest halt. 1 



f ' x Hyde, Deformitv after Fracture of the Neck of the Femur : 20 cases, arranged and 
tabulated. Med. Gazette, April 17, 1880, p. 244. 



368 



FRACTURES OF THE FEMUR 



Treatment. — The treatment is as follows : In case of a complete frac- 
ture within the capsule, existing without laceration of the reflected cap- 
sule, or displacement of the fragments, and equally in case of a fracture 
at the same point with impaction, the treatment ought to be directed to 
the retention of the bone in place, by suitable mechanical means, for a 



Fig. 208. 




Author's apparatus for fractures of the ueck of the femur. 



length of time sufficient to insure bony union, or for so long a time as 
the condition of the patient will warrant. The means which are, in my 
judgment best calculated to fulfil this important indication, are complete 
rest in the horizontal posture, the limb being secured by the same appa- 
ratus which we employ with so much success in fractures of the shaft. 
In fractures of the neck, however, whether within or without the capsule, 

Fig. 209. 




Gibson's modification of Hagedorn's splint. 



we employ no coaptation splints ; and the amount of extension ought to 
be only one-half of that generally employed in fracture of the shaft, say 
about ten pounds. The long side-splint, with a foot- board, to prevent 
eversion of the limb, must not be omitted. 

Another apparatus is Gibson's modification of Hagedorn's, in which the sound 
limb is first secured to the foot-board, and the broken limb is subsequently 
brought down to the same point. By this method, as by my own apparatus, we 
may avoid the necessity of a perineal band, which is so painful, insupportable 
often when the fracture is at the neck. 

In treating this fracture, supposing no displacement to exist, no exten- 
sion beyond that which is necessary to insure perfect quiet can be proper, 
inasmuch as the fragments are not overlapped ; and they need only a 
moderate assistance to enable them to maintain their present position 
against the action of the muscles. Moreover, if the fragments are im- 



NECK OF THE FEMUR. 369 

pacted, violent extension would disengage them, and render their dis- 
placement and non-union inevitable. How long the patient will submit 
to this, or to any other mode of securing perfect rest, is very uncertain, 

Fig. 210. 




Gibson's modified splint applied. 

and the decision of this question must rest with the individual cases and 
the good sense of the surgeon. Xot very many old and feeble people 
will bear such confinement many days without presenting such palpable 
signs of failure as to demand their complete abandonment. The careful 
and judicious application of splints, long continued, and employed under 
the most favorable circumstances, will sometimes fail. 

In the practice of Dr. James E. Wood, a girl, set. 16 years, of vigorous 
constitution, perfectly free from any constitutional taint, either of scrofula, 
syphilis, or cancer, was caught between the wheels of two carriages, the 
one stationary, the other in motion. The blow was received directly on the 
trochanter major of the right side. The symptoms which presented themselves 
showed conclusively that there was a fracture. There were shortening, loss of 
voluntary motion, and eversion ; by placing the finger on the trochanter major, 
and the thumb on the groin, a well-marked crepitus could be felt on extension 
and rotation being made. There was no laceration or other complication of the 
injury. She was placed on Amesbury's splint, with side-splints accurately 
adjusted, and every precaution taken to insure a perfect union. The limb was 
kept on this splint without being disturbed for six weeks. At the end of that 
time it was taken from the splint, and examined with care; the signs of fracture 
still remained. The limb was replaced on the splint, and the dressings applied 
as before ; everything was attended to in the general management of the case 
which the doctor thought would be conducive to perfect union. The patient 
was kept for three weeks longer on the splint, which was then removed. It was 
found that there was no union. At the expiration of three years she died of an 
acute disease. It was found that there had been a transverse fracture of the 
bone just at the junction of the head and neck. The head of the bone was still 
attached to the acetabulum by the ligamentum teres. The process of absorption 
had been going on, and the head of the bone had already been absorbed below 
the level of the acetabulum, and what remained was soft and spongy, easily 
broken w T ith the handle of the scalpel. The neck of the bone was rounded off, 
and covered with a fibrous deposit. This was not a case of diastasis. 

The reasons why I would prefer my own plan have already been stated in part, 
to which I w T ill now add, that if an error should occur in the diagnosis — if it 
should prove finally to have been a fracture without the capsule — then this 
treatment would be correct, and no injury would come to the patient from the 
error in diagnosis ; but if we adopt Sir Astley Cooper's suggestion, namely, to 
get the patient upon crutches as soon as possible, perhaps as early as fourteen 
days, an error in diagnosis might be followed by the most disastrous conse- 
quences. 

[The treatment of fractures of the neck of the femur is still too much governed 
by the opinions of the authorities of the past, who held that bony union in intra- 
capsular fractures is impossible, or so doubtful that old people should not be 

24 



370 FRACTURES OF THE FEMUR. 

subjected to the necessary confinement. There is now abundant evidence that 
intracapsular fractures, properly treated from the first, may unite by bone ; and 
there is still more evidence that, owing to the difficulty of differentially diag- 
nosing intra- and extra-capsular fractures, many patients fail of correct treatment, 
and, as a consequence, remain cripples for life. Nor should too much stress be 
laid on the popular opinion that old people cannot bear confinement. The 
ability of the aged to bear confinement depends altogether upon the care given 
them, and hence every necessary means should be employed to prevent injury 
by confinement, as a suitable bed, rubber air-rings for the hips, etc. • The wiser 
course is to treat every case of fracture of the neck of the femur with the deter- 
mination to secure union if possible. 

The rule being that every case should be treated for union, the treatment 
should from the first be systematic. The bed should be perfectly adapted to the 
age and condition of the patient. Extension should be commenced at once, but it 
should be governed by the following rules : 1. A light weight should at first be 
used, as one to four pounds; 2. If the diagnosis is impaction, this weight should 
be but little, if any, increased, the object being simply to counteract the muscles ; 

3. If there is proof of complete fracture the weight should be increased from day 
to day until the shortening is overcome, or as nearly as possible within one week ; 

4. During this time the limb may be supported laterally by sand-bags ; 5. At 
the end of a week permanent dressings should be applied ; if the fracture is im- 
pacted, a firm bandage extending from the waist to the upper part of the thigh, 
tightly fastened by pins or tapes, will serve to keep the fragments in apposition ; 
if not impacted, and the patient is old, this dressing may be sufficient, but with 
younger and more restless patients along splint, extending from, the waist to the 
foot, will give better support, the splint being well padded and held in place by 
bandages around the body above, and around the limb below ; 6. In hospital 
practice, and in the hands of those familiar with immobile dressings, the plaster- 
of-Paris or silicate appliance is preferable. The patient should not be too early 
released from the dressings. The limit of time required for a cure sufficient to 
bear the weight of the body is scarcely less than six months.] 

In gunshot intracapsular fractures, if suppuration ensues, the head of 
the bone and other fragments ought to be removed ; and there may occur 
cases in which the fragments should be removed immediately, as has been 
done occasionally with satisfactory results. So, also, if after a simple 
intracapsular fracture, suppuration within the joint were to ensue, resec- 
tion would be the proper resort. 

(6) Extracapsular Fracture. 

Like fractures within the capsule, these also occur most frequently 
in advanced life. They are not, however, as often met with in extreme 
old age as are fractures within the capsule ; and they are much more 
often met with in persons of middle age, and in younger persons, 
than are intracapsular fractures. 

Of fractures recognized as extracapsular, in Dr. Hyde's tables, ten were under 
fifty years, and seven at or over fifty. The three youngest were respectively 
thirty, twenty-five, and twenty years of age. Of the 42 recorded by me as extra- 
capsular fractures, I have made no careful tabulation of the ages, but it is certain 
that in general they belong to a younger class of persons than the cases recorded 
as intracapsular. 

Causes. — As to the immediate causes, fractures without the capsule 
seem to be the result generally of falls or of blows received directly upon 
the trochanter ; occasionally, also, they are produced by falls upon the 
feet or upon the knees. 



NECK OF THE FEMUR. 371 

Pathology. — These fractures may occur at any point external to the 
capsule, but generally the line of fracture is at the base, corresponding 
very nearly with the anterior and posterior intertrochanteric crests. 
Almost invariably the acetabular penetrates the trochanteric fragment 
in such a manner as to split the latter into two or more pieces. The 
direction of the lesions in the outer fragments preserves also a remark- 
able uniformity ; the trochanter major being usually divided from near 
the centre of its summit, obliquely downward and forward toward its 
base, and the line of fracture terminating a little short of the trochanter 
minor, or penetrating beneath its base ; while one or two lines of fracture 
usually traverse the trochanter major horizontally. 

In an examination of more than thirty specimens, I have noticed but two or 
three exceptions to the general rules above stated. In Mutter's collection, speci- 
men B 115 is not accompanied with either impaction or splitting of the trochan- 
teric fragment ; but the neck, having been broken close to the intertrochanteric 
lines, has r apparently, slid down upon the shaft about one inch, at which point 
it is firmly united by bone. Dr. Neill has also a specimen of fracture at the 
same point, but without union of any kind, in which no traces remain of a frac- 
ture of the trochanters. The acetabular fragment has moved up and down upon 
the trochanteric until it has worn for itself a shallow socket three inches and a 
half long, the approximate surfaces being smooth and polished like ivory. 

The trochanter major is usually turned backward, the shaft of the 
femur being rotated in this direction, the same as is usually observed in 
other fractures of the neck of the femur. 

I have seen one exception to this general rule in a specimen belonging to 
Mutter (No. 29) ; the trochanter in this instance is turned forward, so that the 
neck is shorter in front than behind. 

The upper fragments of the trochanter major, whenever the lines of 
fracture are transverse, are generally inclined inward toward the neck, 
as if displaced in this direction by the force of the blow, or perhaps by 
the resistance offered by certain muscles and ligamentous bands which 
find an insertion upon its summit. The neck is found, in most cases, 
standing inward at nearly a right angle with the shaft, the head being 
much more depressed than the outer extremity of the neck ; in conse- 
quence of which the lower margin of its broken extremity is driven much 
deeper into the trochanteric fragment than is the upper margin. 

Malgaigne believes that impaction, with consequent fracture of the trochan- 
ters, is never absent in true extracapsular fractures, unless it be in that very 
unusual variety in which the trochanter forms a part of the inner fragment 
(fractures through the trochanter major and base of the neck). Robert Smith 
entertains the same opinion. I cannot agree, however, with either of these gen- 
tlemen that the rule is so invariable. 

It is certain that impaction and comminution of the outer fragment are 
very constant, and that, whether the fracture is produced by a fall upon 
the feet or upon the trochanter major. But the impaction does not nec- 
essarily continue; sometimes, indeed, it does, and the position of the 
limb, whatever it may be at the moment, remains unalterably fixed ; 
either very little or considerably shortened, according to the degree of 



372 



FRACTURES OF THE FEMUR. 



impaction ; rotated outward or inward, or in neither direction, perhaps, 
according to the direction of the force and the amount of comminution. 
In other cases, owing to the extreme comminution, and to the wide sepa- 
ration of the trochanteric fragments, or to the contraction of the muscles 
inserted into the top of the femur, or to the weight of the body in attempts 
to walk, or to injudicious handling on the part of the surgeon, such as 
forcible rotation, by which the neck is made to act as a lever, and actually 
to pry the fragments apart, or to violent extension, by which the impac- 
tion is overcome — owing to some one or several of these causes it often 
happens that the fragments separate, and the leg becomes immediately 
more shortened, movable, and more inclined to rotate outward. 



Fig. 211. 



Fig. 212. 



Fig. 213. 




Impacted extracapsular fractures. (R. Smith, and Eriehsen.) 

Symptoms. — The symptoms which indicate a fracture of the neck of 
the femur without the capsule are pain, mobility, crepitus, shortening, 
and eversion of the limb. The trochanter major is not as prominent as 
upon the opposite side ; and especially where the fragments are not im- 
pacted, but are completely separated, it rotates upon a shorter axis. 
There are also several other signs to which I shall refer when consider- 
ing the differential diagnosis. 

Before considering more in detail the value of these several signs, I wish to 
call attention to a fact which has been often observed by myself and others, 
namely, that the patient is able, sometimes, immediately after this accident, to 
take a few steps ; yet never, perhaps, without considerable pain. The same may 
happen in an intracapsular impacted fracture, but it happens much more often 
in the extracapsular impacted fracture. 



The pain and tenderness, accompanied sometimes with swelling and 
discoloration, are situated most often in front of the neck of the bone. 
Articular mobility exists in a majority of cases ; that is, the limb can 
be moved pretty easily in any direction by the surgeon, but not without 
producing pain or provoking muscular spasms. In most cases the 



NECK OF THE FEMUR. 



373 



Fig. 214. 



patient himself is unable to move the limb by his own volition, or he can 
only move it slightly. Crepitus is present whenever there exists a mode- 
rate but not complete impaction. It is also present 
generally when, the trochanteric fragment having 
been extensively comminuted and loosened, the im- 
paction becomes excessive ; and it is only absent 
when the impaction is such that the fragments are 
completely and firmly locked into each other. A 
shortening is inevitable, at least in all cases accom- 
panied with either temporary or permanent impac- 
tion, and we have seen that one of these conditions 
seldom fails. Eversion of the toes is very constant ; 
but in a few instances upon record the toes have 
been found turned in, or even directed forward. 
The trochanter major usually seems depressed or 
driven iir; and when the two main fragments are 
completely separated, if the limb is rotated, the 
trochanter will be found to turn almost upon its 
own axis, or upon a very short radius. 




--^U> 



Fracture of the neck 01 
the fetnur. (Fergusson.) 



Robert Smith has established the following distinc- 
tion : AVhen the fracture is extracapsular and impacted, 
that is, when it remains impacted, the shortening is only 
moderate, varying from one-quarter of an inch to one 
inch and a half; in fourteen cases measured by him the 
average was a fraction over three-quarters of an inch ; 
but when it does not remain impacted it ranges from 
one inch to two inches and a half; indeed, Mr. Smith 

mentions one example in which the shortening reached four inches, and forty- 
two cases gave an average shortening of something more than one inch and a 
quarter. Mr. Smith's experience as to the amount of shortening in these cases 
agrees very nearly with my own. 

In enumerating the signs of a recent extracapsular fracture, it will be 
seen that I have, with only slight variations, repeated the signs of a frac- 
ture within the capsule. It will become necessary, therefore, to indicate, 
as far as possible, a differential diagnosis. 



Signs of a fracture within the capsule. 

Produced often by slight violence. 

A fall upon the foot or knee, or a trip upon 
the carpet, etc. Possibly a fall upon the tro- 
chanter: especially when an old person is 
the subject of the injury. 

Generally over fifty years of age. 

More frequent in females. 

Pain, tenderness, and swelling less and 
deeper. 

Ecchymosis not often seen. 

(The two following measurements to be 
made from the lower margin of the anterior 
superior spinous process of the ilium to the 
lower extremity of the malleolus externus or 
internus.) 

Shortening at first less than in extracap- 
sular fractures, often not any. 



Signs of a fracture without the capsule. 

Produced usually by greater violence. 

A fall upon the trochanter major in nearly 
all cases. 



Often under fifty years of age. 

Relative frequency in males or females not 
established. 

Pain, swelling, and tenderness greater and 
more superficial. It is especially painful to 
press upon and around the trochanter major. 

Superficial and extensive ecchymosis quite 
frequent. 



Shortening at first greater, almost 
some. 



ilwav; 



374 



FRACTURES OF THE FEMUR. 



Signs of a fracture within the capsule 
{continued). 

Shortening after a few days or weeks 
greater than in extracapsular fractures. 
Sometimes this takes place suddenly, as 
when the limb is moved, or the patient steps 
upon it. 

Measuring from the top of the trochanter 
to the condyles or to the malleoli, the limb is 
not shortened. 

If there is no impaction, the trochanter 
major moves upon a relatively longer radius 
than in cases of extracapsular fractures, the 
pivot being nearer the acetabulum. 

If the patient recovers the use of the limb, 
not restored under many months, or years. 



ISTo enlargement or apparent expansion of 
the trochanter major, after recovery, from 
deposit of bony calius. 



Progressive wasting of the limb for many 
months after recovery. 

Eventually excessive halting, accompan- 
ied with a peculiar motion of the pelvis, such 
as is exhibited in persons who walk with an 
artificial limb. 



Signs of a fracture without the capsule 
{continued). 

Shortening after a few days or weeks less 
than in intracapsular fractures, provided 
proper extension has been maintained. That 
is, the amount of shortening changes but 
little, if at all, if the impaction continues. If 
it does not continue, it shortens more. 

Measuring from the top of the trochanter 
to the cond}rles or to the malleoli, the limb 
may be found a little shortened. 

If there is no impaction, the trochanter 
major moves upon a relatively shorter radius, 
the pivot being more remote from the ace- 
tabulum. 

The patient usually recovers the use of the 
limb sooner. In many cases, however, very 
slowly, and walking is for a long time diffi- 
cult and painful. 

Enlargement or irregular expansion of 
trochanter, which may be felt sometimes dis- 
tinctly through the skin and muscles, and 
which is especially manifest after the lapse 
of some months. 

The limb preserving more nearly its natu- 
ral strength and size 

Comparatively slight halt, motions of hip 
more natural. 



[Allis, of Philadelphia, has noticed the relaxation of the fascia lata above the 
trochanter when there is fracture of the neck of the femur, and illustrates the 
method of detecting this sign (Fig. 215).] 

Prognosis. — In attempting to establish the differential diagnosis, we 
have necessarily been led to consider most of the essential points of 
prognosis. Very little, therefore, remains to be said upon this subject. 
Union occurs as rapidly in this fracture as in fractures of the shaft ; and 
perhaps in general more promptly, owing to the existence of impaction. 
But whether it occurs promptly or slowly, or, indeed, if it does not 
occur at all, a remarkable deposit of ossific matter almost invariably 
takes place along the intertrochanteric lines, where the bone has sepa- 
rated from the shaft, and also, not unfrequently, along the lines of 
the other fractures of the trochanter. This deposit is no less remarkable 
for its abundance than for its irregularity, long spines of bone often rising 
up toward the pelvis and forming a kind of knobby or spiculated crown, 
within which the acetabular fragment reposes. In a few instances these 
osteophytes have reached even to the bones of the pelvis, and formed 
powerful abutments, which seemed to prevent any farther displacement 
of the limb in this direction, and by some writers they have been sup- 
posed thus to fulfil a positive design. A sufficient explanation of their 
existence, however, I think, can be found in the fact that they proceed 
entirely from the trochanteric fragments, whose extensive comminution 
and great vascularity would naturally lead to such results. The same, 
but in a less degree, has already been noticed as occurring in impacted 
fractures at the anatomical neck of the humerus, where certainly such 
bony abutments could not serve any useful purpose. 

Probably in all, certainly in nearly all cases, the limb will be found, 
after the union is consummated, more or less shortened, generally between 



NECK OF THE FEMUR. 



375 



Fig. 215. 



half an inch and an inch. If exceptions ever occur, it must be in those 
examples in which there is no impaction, and it is certain that such 
examples are very rare. Such is 
the united testimony of all surgeons 
whose opinions have ever been re- 
spected as authority ; and the same 
is true of intracapsular fractures. 
What ignorance of the elementary 
facts of surgical science, or insin- 
cerity, then, do these men exhibit 
who affirm that they are able to 
treat all fractures of the femur with- 
out shortening ! E version of the 
foot is not so constant as short- 
ening, but it will be found to exist 
in some degree in a large majority 
of cases, even when the case has 
been managed in the most skilful 
monner ; yet in this regard some- 
thing will depend upon the position 
in which the limb is maintained 
during the treatment. 

Treatment. — The same principles 
of treatment are applicable here as 
in fractures of the neck within the 
capsule ; by which I mean to say 
that, as in all of those examples of 
fracture within the capsule where 
the relation of the fragments is such 
as to warrant a hope that a bony 
union may be consummated, namely, 
where the fragments are not dis- 
placed or are impacted, the straight 
position, with only moderate extension, constitues the most rational mode 
of treatment ; so also in this fracture, whenever the fragments are im- 
pacted and remain impacted, the straight position, with moderate exten- 
sion, employed only as a means of retention, but not so as to overcome 
impaction, is the most suitable. It is only by employing this plan of 
treatment that those serious misfortunes to the patient can be avoided 
which would necessarily continue to occur if the patient were in the one 
case to dispense with apparatus wholly, or to get upon his crutches as 
soon as the condition of his limb and of his body will permit. This con- 
clusion is based upon the admitted difficulty of diagnosis. 

If, as is well understood, the diagnosis between these two varieties of fracture 
is often impossible during the life of the patient, then how shall we know in any 
given case which of the two plans to adopt? If we act upon the supposition 
that it is within the capsule, adopting Sir Astley Cooper's method, and it proves 
to have been a fracture without the capsule, we may do irreparable injury to 
our patient. It is precisely here that this distinguished surgeon committed 
his great error; not in denying that certain specimens' were fractures of the 
neck of the femur within the capsule united by bone, nor in constantly urging 




Method of recognizing the relaxation of 
the fascia lata after fracture of the neck of 
the femur. (Allis.) 



376 



FRACTURES OF THE FEMUR. 



upon his contemporaries the improbability of such an event ; but in that, while 
he admitted its possibility, he chose to recommend a plan of treatment which 
was unlikely to insure such a union, and which, in the uncertainty, if not 
impossibility of diagnosis, was liable, upon his supposed authority, to be adopted 
in many cases of extracapsular fractures. 



Fig. 216. 



Fig. 21 : 





Extracapsular fracture. (Ericlisen.) 



Extracapsular fracture. (R. Smith.) 



Fig. 21 



Again, if the fracture be extracapsular and not impacted, or the im- 
paction has been, for any cause, overcome ; or, if the fracture be intra- 
capsular and not impacted ; or if the capsule is lacerated and the frag- 
ments are in consequence displaced ; then, 
again, no injury need result from the treat- 
ment, if we adopt the straight position with 
moderate extension. That it is or is not 
i^'M impacted we may know generally by the 
I P f' ' : KrjsB amount of displacement, although we may 
Map not easily decide whether the fracture is 

within or without the capsule. Now, the 
amount of shortening will determine prop- 
erly enough the amount of extension to be 
employed. In either case, however, we 
shall not employ as much extension as in 
fractures of the shaft ; and while, if it be 
an intracapsular fracture, we may only gain 
a shorter and firmer ligamentous union, if 
it proves to be extracapsular we shall in- 
sure a better and more speedy bony union. 




Extracapsular fracture. 



If any surgeon, acting upon the suggestions here made, shall confine a feeble 
or an aged person in the horizontal posture, with or without a straight splint, 
until the powers of nature have become exhausted, and death ensues, as our 
readers have already been admonished may happen, we are not to be held respon- 
sible for his want of judgment or of skill. We have advised this plan of treat- 



NECK OF THE FEMUR 



377 



ment only for so long a period as the condition of the patient renders it entirely 
safe, or as it can prove useful. Xo doubt, then, in a large number of cases, it 
will have to be abandoned very early, and in not an inconsiderable proportion 
all constraint will be plainly inadmissible from the beginning. 1 



Fig. 219. 




Miller's splint for extracapsular fracture. (From Miller.) 

(c) Fractures of the Neck, Intra- and Extra-capsular. 

It is scarcely necessary to say that the line of fracture through the 
neck of the femur may be such, that it shall be in part within and in 
part without the capsule ; and such fractures will be even more difficult 
to diagnosticate than either of those forms of which we have just spoken. 



Fig. 220. 



Fig. 221. 




Fracture along the intertrochanteric line, 
being intra- and extra-capsular. (Pick.) 




Displacement which results from muscu- 
lar action in fracture of the neck ; the letters 
indicate the several muscles. (Hind.) 



The symptoms will be mainly, however, those which characterize frac- 
tures within the capsule, while the treatment ought to be such as we 
would adopt in those fractures which are wholly without the capsule. 



1 Fracture at the Neck of the Femur. Clinical Lecture at the Bellevue Hospital, by the 
Author. Priority in Employment of Extension, etc. The Medical Record, March 9, 187S. 



378 



FRACTURES OF THE FEMUR. 



The chances for bony union are increased in proportion as the line of 
separation extends outside of the capsule, and we ought to be diligent in 
our efforts, if we have made ourselves certain that the fracture is partly 
extracapsular, to secure a good bony union ; a result which experience 
has shown may be reasonably anticipated. 

[Ogston gives three fragments to these fractures, viz., the head and neck, the 
trochanter major, and the shaft of the femur. Pick states that " where no im- 
paction occurs there is always more displacement than in the intracapsular 
variety. The line of fracture being, for the most part, external to the capsular 
ligament, there is nothing to oppose the force of the muscular action upon the 
lower fragment, which is drawn upward by the glutei muscles and the combined 
action of the rectus femoris in front, and the biceps, semi-tendinosus, and semi- 
membranosus behind ; and is, at the same time, everted from the same causes 
which produced eversion in the intracapsular fracture. (Fig. 221.)] 

The necessity for some extension, and of firm retentive apparatus in this form 
of fracture, furnishes another argument in favor of the employment of the same 
means in fractures wholly within the capsule. We shall thus avoid the mischief 
which might anise from mistaking a fracture of the character of which we are 
now speaking, for a fracture wholly within the capsule. 

[Senn, of Milwaukee, advises fixation of the limb in impacted fractures, and in 
non-impacted fractures reduced, by means of a plaster- of-Paris dressing, with a 
splint and pad for compression. The following is his description of the applica- 

Fig. 222. 




Senn's splint. 

tion of the apparatus : The patient is dressed in well-fitting knit drawers and a 
thin pair of stockings. For strengthening the plaster-of-Paris dressing over the 
joints, and at other points where greater strength is required oaken shavings are 
placed between the layers of plaster ; these small thin, splints greatly increase 
the durability of the dressing without adding much to its weight. The bony 
prominences are protected with cotton before the plaster-of-Paris dressing is 
applied. The drawers and stockings furnish a more complete and better pro- 
tection to the skin than roller bandages. Usually about twenty-four plaster-of- 
Paris bandages are required for a dressing. The fractured limb is first encased 
in the dressing as far as the middle of the thigh, when the patient is lifted out 
of bed by two strong persons, the physician supporting the limb so as to prevent 
disengagement of the fragments if the fracture is impacted, and to guard against 
additional injuries in non-impacted fractures. The patient is placed in the 
erect position, standing with his sound leg upon a stool or box about two feet in 
height ; in this position he is supported by a person on each side until the dress- 
ing has been applied and the plaster has set. A third person takes care of the 
fractured limb, which is gently supported and immovably held in impacted frac- 
tures until permanent fixation has been secured by the dressing. In non-im- 
pacted fractures the weight of the fractured limb makes auto-extension, which 
is often quite sufficient to restore the normal length of the limb ; if this is not 
the case, the person who has charge of the limb makes traction until all short- 
ening has been overcome, as far as possible, at the same time holding the limb 



FRACTURES OF THE TROCHANTER MAJOR. 



379 



Fig. 223. 



in a position so that the great toe is on a straight line with the inner margin of 
the patella and the anterior superior spinous process of the ilium. In applying 
the plaster-of-Paris bandages over the seat of fracture, a fenestrum, correspond- 
ing in size to the dimensions of the compress with which the lateral pressure is 
to be made, is left open over the great trochanter. To secure perfect immobility 
at the seat of fracture, it is not only necessary to include in the dressing the 
fractured limb and the entire pelvis, but it is absolutely necessary to include the 
opposite limb as far as the knee, and to extend the dressing as far as the car- 
tilage of the eighth rib. The splint, which is represented by Fig. 222, is incor- 
porated in the plaster-of-Paris dressing, and must be carefully applied so that 
the compress, composed of a well-cushioned pad with a stiff, unyielding back, 
rests directly upon the trochanter major, and the 
pressure which is made by a set screw is directed 
in the axis of the femoral neck. The set screw is 
projected by a key which is used in regulating the 
pressure. Lateral pressure is not applied until 
the plaster has completely set. If the patient is 
well supported and the fractured limb is held im- 
movably in proper position, but little pain is ex- 
perienced during the application of the dressing. 
Syncope should be guarded against by the admin- 
istration of stimulants. As soon as the plaster 
has sufficiently hardened to retain the limb in 
proper position, the patient should be laid upon a 
smooth, even mattress, without pillows under the 
head, and in non- impacted fractures the foot is 
held in a straight position, and extension is kept 
up until lateral pressure can be applied. The 
lateral pressure prevents all possibility of disen- 
gagement of the fragments in impacted fractures, 
and in non-impacted fragments it creates a con- 
dition resembling impaction by securing accurate 
apposition and mutual interlocking of the uneven 
fractured surfaces. No matter how snugly a plaster- 
of-Paris dressing is applied, as the result of shrink- 
age in a few days it becomes loose, and without 
some means of making lateral pressure, it would 
become necessary to change it from time to time 
in order to render it efficient. But by incorporating a splint, as shown in Fig. 
222, in the plaster dressing (Fig. 223) this is obviated, and the lateral pressure 
is regulated from day to day by moving the set screw, the proximal end of which 
rests in an oval depression in the centre of the pad. From time to time the 
pad is removed, and the skin washed with diluted alcohol for the purpose of 
guarding against decubitus.] 




Serin's dressing complete. 



§ 2. Fractures of the Trochanter Major. 

(a) Fracture through the Process. — Cooper 1 says: "Fractures some- 
times happen through the trochanter major obliquely, and the cervix 
ossis femoris does not participate in the injury." The illustration, 
Fig. 224, "exhibits," he says, "the seat of fracture of the trochanter 
major often mistaken for fractured cervix femoris ; this fracture unites 
by bone.'' The line of this supposed fracture, as shown in the illustra- 
tion, is from near the top of the trochanter major downward and inward, 
and terminating on the shaft just below the trochanter minor. It does 
not, therefore, involve the neck, but it severs the thigh-bone completely." 

Sir Astley Cooper believed that he had seen three other similar cases in the 
course of his practice, none of which, however, was established by dissection. 

1 Sir Astley Cooper, on Dislocations and Fractures of the Joints, London, 2d ed., 1823, p. 158. 



380 



FRACTURES OF THE FEMUR. 



Fig. 224. 



I am compelled to state that the fracture described by Sir Astley, 
unaccompanied with comminution of the trochanter major, has probably 
never been met with. The illustration which he 
furnished of this accident was drawn, not from 
any such specimen seen by himself, but from his 
own ideas as to what conditions of the fracture 
would best explain the clinical phenomena pre- 
sented. Surgeons of Sir Astley's day had not 
become so well acquainted with the variety of con- 
ditions in which an extracapsular impacted frac- 
ture may be found — in some cases the penetration 
being almost imperceptible, while in others the 
penetration is such as to separate the trochanter 
into several fragments, some of which may be com- 
pletely detached and displaced. 




Sir Astley Cooper's im- 
aginary fracture through 
the trochanter major. 



Sir Astley Cooper's error in diagnosis, as Malgaigne 
does not hesitate to call it, has embarrassed and misled 
many who have attempted to study this subject; and 

which embarrassment can only be relieved by a complete rejection of all that 

Sir Astley has written upon it. 



(b) Fracture of the Process. — [A distinction should be made between 
a fracture through the trochanter major and a fracturing off of the 
process.] 

[Fracture of this bone is very rare, but its existence has been proved by 
dissection. The epiphysis maybe fractured off at its base, or it may be crushed. 
The more frequent cause is direct violence, as a fall upon the 
trochanter. The symptoms are, pain and swelling at the seat 
of fracture, absence of prominence of the trochanter, ability 
to seize the fragment of bone and move it separately from 
the shaft, crepitus when the limb is abducted, and no short- 
ening. The prognosis is unfavorable as regards union. The 
treatment must be such as will maintain the fragments as 
nearly in apposition with the shaft as possible. Abduction 
of the limb was recommended by Bransby Cooper, and this 
position will certainly approximate the separated parts. In 
other respects the patient should be confined to the recum- 
bent position for a period of at least one month.] 

The case reported by Waechter 1 may be given as an illus- 
trative example. A man 71 years old, fell upon his left hip ; 
there was no sign of contusion and no crepitus. Outward 
rotation alone caused pain. Subsequently the limb became 
flexed, rotated inward and adducted. Four weeks after the 
accident he died of pneumonia. "The upper and inner por- 
tion of the trochanter was separated by a line of fracture 
which lay entirely outside the joint, beginning close by the 
upper edge of the insertion of the capsule, running down- 
ward and outward, and then up across the top of the tro- 
chanter. The fragment, which was split into two pieces that 
were slightly movable on each other, was slightly displaced 
backward and inward, and the periosteum was torn in front, 
but not on the outer side. The tendons of the pyriformis, 
obturator internis and gemelli, and the anterior fibres of the 
glutseus medius, and upper fibres of the glutseus minimus remained attached 




Fracture of the tro- 
chanter major. 



1 Deutsche Zeit. fur Chirurgie, 1877, p. 104. 



FRACTURES OF THE TROCHANTER MAJOR. 



381 



Fig. 226. 



I have also myself reported one example of this fracture as having come under 
my own observation. The patient, J. R., set. 23, fell from a high wagon, striking 
upon his left hip. When he got upon his feet, he found himself unable to walk, 
and was carried to his room. Fourteen days after the accident I saw the patient 
with Dr. Wilcox. The thigh was not appreciably shortened, nor was there any 
eversion or inversion; but the epiphysis of the trochanter major was carried 
upward toward the crest of the ilium half an inch, and slightly sent in. No 
crepitus could be detected. The splint was continued five weeks ; and about a 
month after, I found the fragment in the same place, but he was able to walk 
with only a slight halt. 

(c) Separation of the Epiphysis of the Trochanter Major. — [Separa- 
tion of the epiphysis of the trochanter in young persons is a rare accident. 
It is more often caused by a direct injury to the trochanter, but in some 
cases it seems to have been due to muscular action. There is eversion of 
the foot, a swelling over the trochanter, and inability to use the limb freely. 
In many cases there was the rapid formation of an abscess, with a tendency 
to pyaemia. The treatment must be, rest with the limb straight but abducted.] 

Mr. Key reported the following case: A girl, aged about 16 years, fell upon 
the sidewalk, and struck her trochanter violently against the curbstone. She 
arose, and, without much pain or difficulty, walked home. 
The right leg, which was the one injured, was consider- 
ably everted, and appeared to be about half an inch 
longer than the sound limb. It could be moved in all 
directions, but abduction gave her considerable pain. 
She had perfect command over all the muscles, except 
the rotators inward. Xo crepitus could be detected. 
Four days after admission she died. The autopsy dis- 
closed a fracture through the base of the trochanter 
major, but without laceration of the tendinous expansions 
which cover the outside of this process, so that no dis- 
placement of the epiphysis had occurred, nor could it be 
moved, except to a small extent upward and downward. 
A considerable collection of pus was found, also, below 
and in front of the trochanter. The absence of displace- 
ment in the fragment, with its peculiar and limited 
motion, sufficiently explained why the fracture could not 
be detected during life. 

A case was reported by McCarthy to the London Pathological Society, and is 
printed in its Transactions as "a traumatic separation of the trochanteric epi- 
physis." The patient was a girl eight years old, who, when brought to the 
hospital, was considered too ill to be examined, and died a few hours afterward. 
The history was, that she had never had any illness previous to a fall on the 
left side a week before, while playing. A day or two later a lump was noticed ■ 
on the left hip, and the child was kept in bed in oonsequence. A few days later 
her breathing became so difficult that she was brought to the hospital, walking 
the distance, half a mile, and not complaining of pain. The autopsy showed 
" pyaemic pericarditis, pleurisy, and pneumonia," a large extra-peritoneal abscess 
in the pelvis, connecting along the tendon of the pyriformis with another around 
the neck of the femur. The trochanteric epiphysis was completely detached 
from the shaft, but held in position by tendinous attachments and reflections of 
the capsule. 1 

Prof. Eoddick, of Montreal, Canada, 2 reports a case. A lad, set. 16, became 
lame in consequence, as Dr. Roddick thinks probable, of leaping a fence in 
pursuit of a bail. Subsequently an abscess formed over the trochanter, which 
was opened. A few weeks later he died, apparently as a consequence of pyaemic 
infection. It was then found that the trochanter was lying in a mass of pus, 
entirely separated from the shaft, and with no other lesion. 




Mr. Aston Key's case. 
Prep. 1195, Guy's Mu- 
seum. (From Brvant.) 



1 McCarthy, Trans. Path. Soc. London, vol. xxv., 1874, p. 200 (Stimson). 

2 Roddick, Canada Med. and Surg. Journ , Xov. 1875, p. 207. 



382 FRACTUKES OF THE FEMUR, 



§ 3. Fractures of the Shaft of the Femur. 

Causes. — Unless the fracture has taken place just above the condyles, 
or immediately below the trochanter minor, in a very large proportion 
of cases it has been produced by a direct blow. The bone is most 
frequently broken in its middle third, and usually at a point somewhat 
above the middle of the shaft. 

Iq an examination of twenty- four fractures of the shaft belonging to Dr. 
Miitter three were in the upper third, two in the lower, and nineteen in the 
middle third. 

In the adult these fractures are, with only an exceedingly rare excep- 
tion, oblique ; and the obliquity is generally greater than in the case of 
other bones. 

This fact, which is very difficult to determine, in most cases, upon the living 
subject, I have established by a considerable number of observations made upon 
cabinet specimens. A transverse fracture is found only twice in Dr. Mussey's 
collection, containing thirty examples of fracture of the shaft; and in Dr. 
Mutter's collection, specimen B 71 is an adult femur, broken nearly transversely 
through its middle third ; and it is united with a shortening of about one inch. 

The direction of the obliquity varies exceedingly, especially in the 
middle and upper thirds ; in the middle third, however, it is generally 
downward and inward ; but in the lower third its direction is, with only 
rare exceptions, downward and forward, and the superior fragment is 
found lying in front of the inferior. 

It is more common to find a transverse fracture in the middle third 
than at any other point of the shaft of the bone ; but in the upper third 
the obliquity is extreme and almost constant. At whatever point of the 
shaft the bone is broken, the degree of obliquity is generally such that 
the fragments cannot support each other when placed in apposition ; 
unless indeed the fracture is near the condyles, where the greater breadth 
of the bone creates an additional support ; but even here the cabinet 
specimens still present a striking obliquity, with more or less overlapping. 
In the case of children, and especially of infants, the bone is not unfre- 
quently broken transversely or nearly transversely, or it is serrated or 
denticulated, so that complete lateral displacement is much less frequent. 

The direction of the displacement, however, in fractures of the shaft 
of the femur, does not always depend upon the direction of the line of 
fracture. In fractures of the upper third, whatever may be the direc- 
tion of the line of fracture, the lower end of the upper fragment inclines 
forward and outward, and the upper end of the lower fragment inward ; 
unless, indeed, this inclination is controlled by actual entanglement of 
the broken ends with each other. In the middle third the fragments also 
generally take the same relative position, whatever may be the direction 
of the fracture ; but when the fracture takes place at or near the con- 
dyles, where the diameter of the bones is much greater, the direction of 
the obliquity determines pretty uniformly the direction of the displace- 
ment. 



FRACTURES OF THE SHAFT OF THE FEMUR. 383 

Symptoms. — The symptoms which characterize a fracture of the shaft 
of the femur are those which are common to all fractures, namely, mo- 
bility, crepitus, displacement of the fragments, pain, and swelling, to 
which are added generally a shortening of the limb, with eversion of the 
foot and leg. Owing to the great amount of muscle covering the thigh, 
or to the swelling which immediately follows the injury, it is sometimes 
difficult to determine at what precise point the fracture has occurred : 
and it is generally still more difficult to say whether the fracture is 
oblique or transverse ; indeed, this latter question is sometimes decided 
approximately by a reference to the age of the patient rather than by the 
examination of the limb. The immediate shortening varies from half 
an inch to an inch and a half, or even more ; and it will average about 
one inch in the case of healthy adults. 

Prognosis. — Whatever may have been the general opinion of experi- 
enced surgeons as to the question of shortening in other fractures, very 
few certainly have ever claimed that in fractures of the femur a com- 
plete restoration of the bone to its original length was generally to be 
expected. There seem, however, to have existed only certain vague and 
indefinite notions as to the proportion and amount of this shortening, 
and which had for their basis nothing better than a few imperfect observa- 
tions. The average shortening in fractures of the upper third of the 
femur, in the cases examined by me, was about four-fifths of an inch ; 
in the lower third it was a fraction over three-quarters, and in the middle 
third a fraction less than three-quarters of an inch ; and the average of 
the whole number was almost exactly three-quarters of an inch (three- 
quarters and one forty- seventh). These analyses were made upon simple 
fractures, and were exclusive of those in which no shortening at all oc- 
curred. An analysis which included also those which had not shortened, 
reduced the average shortening to half an inch and about one-tenth. 

An examination of cabinet specimens does not present a result so favorable even 
as this. Of nineteen fractures of the shaft of the femur contained in Mutter's 
cabinet, not one seems to have been shortened less than one inch. 

Says Chelius : " Fracture of the thigh-bone is always a severe accident, as the 
broken ends are retained in proper contact with great difficulty. The cure 
takes place most commonly with deformity and shortening of the limb, espe- 
cially in oblique fractures, and those which occur in the upper and lower third." 1 
Says John Bell: "The machine is not yet invented by which a fractured 
thigh-bone can be perfectly secured." And Benjamin Bell declares that " an 
effectual method of securing oblique fractures in the bones of the extremities, 
and especially of the thigh-bone, is perhaps one of the greatest desiderata of 
modern surgery." 2 Nelaton remarks: "A fracture of the body of the femur, 
with an adult, is always a grave accident, inasmuch as it demands so long a con- 
finement to the bed, and especially on account of the shortening of the limb, 
which it is almost impossible wholly to prevent; accordingly, Boyer recom- 
mends to the surgeon, from the first day, to announce to the parents of the 
patient the possibility of this accident. With infants, on the contrary, it is 
almost always easy to avoid the shortening." 3 

Malgaigne declares his opinion on this subject thus : " At a period quite recent, 
Desault pretended to cure all fractures without shortening, and his journal con- 
tains several examples. In imitation of Desault, various practitioners have 

1 System of Surgery, by J. M. Chelius, translated, etc., by South. First Amer. ed., vol. 
i. p. 627, 1847. See also p. 625, paragraph 679. 

2 System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801. 

3 Elemens de Pathologie Chirurgicale, par A. Nelaton, torn. prem. p. 752. Paris, 1844. 



384 FRACTURES OF THE FEMUR. 

modified, corrected, and improved the apparatus for permanent extension, and 
they claim to have themselves obtained as complete success. I ought, then, to 
declare here, in the most positive manner, that I have never obtained like re- 
sults, either in the use of my own apparatus, or with that of others, nor indeed, 
where, in pursuance of my invitation, several inventors have applied their appa- 
ratus in my wards. I have examined, more than once, persons declared cured 
without shortening, and yet, upon measurement, the shortening was always 
manifest. The misfortune of all those who believe that they have obtained 
those miraculous cures is, that they have not even thought of instituting a com- 
parative measurement of the two limbs ; I will say even more, that they are most 
generally ignorant of the conditions of a good and faithful measurement. Some- 
times, also, they have been deceived in another way— in falling upon fractures 
which were not displaced, especially with young persons ; and they have believed 
that they have cured with their apparatus a shortening which had never existed. 
In short, when the fragments are not displaced, or even when they are brought 
again into contact and maintained by their reciprocal denticulations, it is easy 
to cure the fracture of the femur without shortening ; aside of those two condi- 
tions, the thing is simply impossible.'' 

Dr. Buck, of New York, thinks that with a shortening of one inch, or even 
one inch and a half, the patient may have " a useful limb, with little or no halt." 1 
Mott testified, in a suit for malpractice, that " more or less shortening of the 
limb is uniformly the result after fractured thigh, even in the most favorable 
circumstances." 2 Knight says: "I have seen but few fractures of the femur in 
the adult, unless of the most simple kind, in which there was not some remain- 
ing deformity; often slight, so as not to impair the usefulness of the limb, and 
in others considerable and apparently unavoidable. In the greater proportion 
of the fractures in children the recovery has been so nearly perfect that no 
marked deformity or lameness has followed." Detmold, of New York, declares 
his belief that a shortening of the femur always occurs after fracture, and that 
" but one inch of shortening in an average of twenty cases is a good result." 3 
Dr. J. Mason Warren, of Boston, writes as follows: "I would state that, after 
a long and very careful observation, I have never yet seen, either in Boston or 
elsewhere, an oblique fracture of the thigh, in a patient over seventeen years of 
age, in which there was not some shortening. I have had cases shown to me in 
which it was averred that the limb was not shortened, but on measuring myself 
I have found the fact otherwise. In children, I believe that union without 
shortening may be accomplished." 

Bigelow, of Boston, writes as follows : " In our hospital cases shortening is the 
rule in adults. Young subjects do better. Three-quarters of an inch shortening 
in the adult is a good result, and easily compensated by the pelvis. Greater 
shortening may occur." 

Says Dr. Buck, of New York : " After carefully scrutinizing over one hundred 
cases of fracture of the femur, taken from the register of the New York Hospital, 
and eliminating such as involved the cervix, or condyles, or belonged to the class 
of compound fractures, there remained an aggregate of seventy-four cases, of 
both sexes, and of all ages from 3 to 63, in which the shaft of the femur alone 
was fractured." In all these cases the difference in the length of the fractured 
limb, resulting from the treatment, was ascertained by careful measurement with 
a graduated tape, and the following deductions were drawn from the analysis : 
" Of the 74 cases of all ages, 19 resulted without any shortening, a proportion of 
about one-fourth. The average shortening of the remaining 55 cases was a frac- 
tion less than three-fourths of an inch. Seventeen cases in the above aggregate 
were under 12 years of age, of which six resulted without any shortening, a pro- 
portion of about one-third. The average shortening in the remaining eleven 
cases was a fraction less than one-half an inch. Of the 57 cases over 12 years of 
age, 13 resulted without any shortening, a proportion of about one-fourth ; and 

1 New York Journ. of Med., vol. xvi. p. 294. 

2 Boston Med. and Surg. Journ., vol. xxxiv. p. 450. See also opinions of Drs. Reese, Post, 
Parker, Cheeseman, "Wood, etc., in relation to the prognosis in this particular case. 

3 New York Journ. of Med., second series, vol. xvi. p. 261. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



385 



the average shortening in the remaining 44 cases was a fraction over three- 
fourths of an inch." 1 

Mr. Holthouse, surgeon to Westminster Hospital, states that a careful exam- 
ination of fifty cases of fractures of the femur in the various London hospitals, 
made by himself, showed that 90 per cent, (including twenty children) were 
shortened, the amount of shortening ranging from one-half an inch to three and 
one third ; and as some of these cases were still under treatment, he entertains a 
doubt whether the final result will prove to be as favorable as above stated. He 
declares, with a frankness which is most creditable to his courage and honesty, 
that at Westminster, with all the appliances known to surgery at his command, 
he has never succeeded, in the adult, in effecting union without shortening. He 
has also examined more than one hundred specimens in the various museums of 
the metropolis, and they are all shortened. 

After quoting the opinions of several writers upon this subject, including the 
author of this treatise, Mr. Holthouse adds in a footnote: "Notwithstanding 
this strong testimony, surgeons are still to be found hardy enough, or ignorant 
enough, to repeat the fallacies which have been so often refuted, and to vaunt 
their success in the cure of oblique fractures in the adult without shortening. 
Why do not these surgeons, instead of publishing their cases in the journals, 
produce their patients at some of the medical societies ?" 2 

Dr. Agnew, 3 after referring to these statements of Mr. Holthouse, says: "My 
own experience accords entirely with these statements. I have not met with a 
single case among all the specimens in Philadelphia of fracture of the shaft of 
the femur which was entirely free from deformity ; and I am equally certain 
that neither in hospital nor in private practice, save in the case of children, 
have I ever succeeded in curing a case without an appreciable deformity." 

It is not to be denied, however, that a few surgeons in all parts of the 
world have claimed, and still continue to claim, in their own practice, or 
from the adoption of their own peculiar plans of treatment, much better 
success. Indeed, some of them do not hesitate to affirm that, as a gen- 
eral rule, any degree of shortening is quite unnecessary. 




Liston's method, recommended by Samuel Cooper, Fergusson, Pirrie, and others. 

In conclusion, I wish to say briefly that, in view of all the testimony 
which is now before me, I am convinced — 

First." That in the case of an oblique fracture of the shaft of the femur 
occurring in an adult, whose muscles are not paralyzed, but which offer 
the ordinary resistance to extension and counter-extension, and where 
the ends of the broken bone have once been completely displaced, no 
means have yet been devised by which an overlapping and consequent 
shortening of the bone can generally be prevented. 4 



1 Buffalo Med. Journ., vol. xv. p. 22, June, 1859. 

2 Holthouse, Holmes's System of Surgery, 2d ed., 1870, vol. ii. p. 866. 

3 Agnew, Principles and Practice of Surgery, vol. i. p. 948. 

4 In the first three editions of this treatise the word " generally " is omitted; but a later 
experience, with improved appliances, has supplied to me, both in my own practice and in the 
practice of others, a few examples of perfect union under the conditions named. The word 

25 



386 FRACTURES OF THE FEMUR. 

Second. That in a similar fracture occurring in children or in persons 
under fifteen or eighteen years of age, the bone may quite often be made 
to unite with so little shortening that it cannot be detected by measure- 
ment ; but it must not be forgotten that with children especially it is 
exceedingly difficult to measure very accurately. 

Third. That in transverse fractures, or oblique and denticulated, oc- 
curring in adults, and in which the broken fragments have become com- 
pletely displaced, it will generally be found equally difficult to prevent 
shortening ; because it will be found generally impossible to bring the 
broken ends again into such apposition as that they will rest upon and 
support each other. 

Fourth. That in all fractures, whether occurring in adults or in chil- 
dren, where the fragments have never been completely or at all displaced, 
constituting only a very small proportion of the whole number of these 
fractures, a union without shortening may always be expected. 

Fifth. That when, in consequence of displacement, an overlapping 
occurs, the average shortening of simple fractures in adults, where the 
best appliances and the utmost skill have been employed, is from one- 
half to three-quarters of an inch. 

If we consider the muscles alone as the cause of the displacement in 
the direction of the long axis of the shaft, the shortening of the limb, 
other things being equal, must be proportioned to the number and power 
of the muscles which draw upward the lower fragment. This will vary 
in different portions of the limb, but nowhere will this cause cease to 
operate, nor will its variations essentially change the prognosis. Other 
causes operate occasionally in the production of shortening, but muscular 
contraction is the cause by which this result is chiefly determined, and 
its power will be ordinarily the measure of the shortening. 

Measurement of the Thigh. — The fact that a patient walks without 
any halt, is no evidence that the limb is not shortened. In this regard 
patients are very unlike ; one having a shortening of only half or three- 
quarters of an inch may limp perceptibly, while another with a shorten- 
ing of an inch, or even an inch and a half, may not limp at all. This 
has been frequently observed ; and it will be easily understood if, standing 
erect with the right foot on a block one and a half inches in height, the 
left foot is planted upon the floor. It will then be seen that the left foot 
can be brought to the floor without disturbing the erect position of the 
body. Nor is it any more a proof that the limb is not shortened because, 
while in the recumbent posture, the heel can be brought down to the 
level of the other. 

Measurements made from the umbilicus, or from the symphysis pubis, 
are always indefinite and unreliable. Velpeau's idea of measuring from 
the folds of the belly, immediately above the ilium, is unsound. Mr. 
Bryant's suggestion that we measure from the trochanter major, by what 
he terms the ilio-femoral triangle, in order to determine the question of 

" generally " was, therefore, added in the fourth edition, and is retained in this. Exactly 
what percentage of perfect cures may reasonably be expected cannot at present be deter- 
mined, but it is certainly very small. It has never been my opinion that a shortening 
must inevitably result as a consequence of the absorption of the ends of the bone. "When 
shortening occurs I think it is always, or almost always, the result of overlapping of the 
fragments. 



FKACTUKES OF THE SHAFT OF THE FEMUR. 



387 



a fracture of the neck, is liable to the very serious objection that the 
exact position of the top of the trochanter cannot, in most cases, be 
clearly determined. 

[Bryant's ilio-femoral triangle (Fig. 228) is formed as follows: CB is the base- 
line, the two sides of the triangle are made up of two lines drawn frem the ante- 

Fig. 228. 




Bryant's ilio-femoral triangle. 

rior superior spinous process of the ilium, one, AC, being vertical and traversing 
the outside of the hip to the horizontal plane of the body; and the second, A B, 
impinging on the tip of the trochanter major; the test-line, CB, for fracture or 
shortening of the neck joins the two at right angles to the vertical line and ex- 
tends from it to the trochanter. The pelvis must be straight. Any shortening 
of this line, on comparing it with the same taken on the other side, indicates 
with precision a shortening of the neck of the thigh-bone. Bryant states that 
" compared with this line, all other measurments are uncertain." For practical 
purposes the vertical line A C, and the test-line C B, are alone required. In Fig. 
229, the line A shows the normal length of the base of the ilio-femoral triangle, 
and B, the shortened base of the ilio-femoral triangle; C shows the horizontal 
level of the fractured bone, and D the horizontal level of the sound bone.] 

Fig. 229. 




Elevation of trochanter of fractured bone. (Bryant.) 



The method most generally practised, is to measure from the round 
end of the anterior superior spinous process of the ilium to the internal 
or external malleolus ; but even this is not very trustworthy. It is 
exceedingly difficult to note accurately the same point upon the two 
sides ; and an error of half an inch is very common when this method is 
adopted. 



388 FRACTURES OF THE FEMUR. 

The patient should repose upon his back, upon an even surface, with 
the lower extremities as nearly as possible in line with the axis of the 
body, the two wings of the pelvis being in the same (horizontal) line. 
A flexible, but firm, graduated tape is to be preferred to the steel tape 
measure. The foot being steadied by an assistant, the surgeon should 
put his thumb-nail against the line where it joins the ring, and push his 
nail into the skin just below the anterior superior spinous process of the 
ilium, pressing firmly up and back, the flat surface of the nail resting 
upon the skin. In this way he will obtain a fixed point, and he can 
obtain an exactly corresponding point upon the opposite side. Below, 
the measurement may be made from either malleolus, but the outer has 
the most defined extremity, and is generally to be preferred. In most 
cases, for some months after the termination of the treatment, there is 
some swelling about the ankle, which renders it necessary to use great 
care in defining the point of the malleolus. The thumb-nail of the oppo- 
site hand may be used for this purpose, resting vertically upon the skin 
(flat against the lower end of the malleolus). The same method may be 
employed in measuring a leg as in measuring a thigh. 

Allusion has already been made in the chapter on General Prognosis to the 
fact that the bones of the lower extremities, as well as other long bones, are not 
always, nor perhaps generally, in the normal condition, of exactly equal lengths. 
J. G. Garson, of London, in the examination of seventy skeletons, ranging from 
twelve years upward, found only ten per cent, which were of exactly equal 
length. 1 Corydon La Ford, Professor of Anatomy at Ann Arbor, however, in 
the measurement of skeletons, found the inequality of the length of the lower 
limbs exceptional rather than as constituting the rule. Garson and Wight agree 
that the left leg was most often the longest. In Garson's measurements the left 
leg was longest in 38 cases, and the right in 25 cases. In most cases these dif- 
ferences are slight, but occasionally they are considerable. As to the practical 
deductions to be made from this fact of asymmetry, it has been sufficiently con- 
sidered in the chapter on General Prognosis. 

[We have already urged the importance of manipulating a thigh which is 
supposed to be fractured the least possible in making a diagnosis. Bryant, of 
London, enforces this precaution in the following emphatic language: "If it 
were as distinctly understood as it should be by all students and practitioners 
that a fracture of the neck of the thigh-bone can be diagnosed without seeking 
for crepitus, that all but the gentlest manipulation of an injured hip is likely to 
prove injurious, and that any attempt to elongate the limb by forcible extension, 
to flex it, or to rotate it with the view of restoring it to its natural position is 
likely to be followed by a breaking up of the impacted bones, and consequently 
by irreparable injury, the treatment of these cases would be as satisfactory in its 
results as it is simple, and our workhouses would be occupied with fewer 
cripples." As bearing on the prognosis, we cannot forbear enforcing our pre- 
viously expressed opinion of the importance of treating every case of fracture 
of the thigh as if union would follow, by quoting, as follows, from Mr. Bryant: 
"If, moreover, it was recognized, as it should be, that many intra-capsular and 
all extra-capsular fractures unite when rightly treated, every case of fracture of 
the neck of the femur, impacted or non-impacted, intra- or extra-capsular, in 
the young, middle-aged, or old, would be treated as if repair and union were 
sure to take place if the parts are kept at rest and in apposition, and in the large 
proportion of cases the hopes of the surgeon will not be disappointed."] 

Treatment. — All the early surgeons, so far as we know, adopted the 
straight position in the treatment of fracture of this bone, either with 

1 Garson, Amer. Journ. Med. Sci., Oct. 1879, from Journ. Anat. and Phys., July, 1879. 
vol. xiii. p. 502. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



389 



simple lateral splints, or with long splints, with or without extension, or 
with only rollers and compresses, or with extension alone. Such was 
the unanimous opinion and practice of surgeons until about the middle of 
the last century, at which time Percival Pott wrote his remarkable trea- 
tise on fractures, a work distinguished for the originality and boldness 



Fig. 230. 




Double inclined plane formerly employed in Middlesex Hospital, London. 



of its sentiments, and which was destined soon to revolutionize, especially 
throughout Great Britain, the old notions as to the treatment of frac- 
tures, and to establish in their stead, at least for a time, what has been 
called, not inappropriately, the "physiological doctrine," the peculiarity 
of which doctrine consisted in its assumption that the resistance of those 
muscles which tend to produce shortening can generally be sufficiently 
overcome by posture, without the aid of extension ; and that for this pur- 
pose, for example, in the case of a broken femur, it was only necessary 
to flex the leg upon the thigh, and the thigh upon the body, laying the 
limb afterward quietly on its outside upon the bed. 

Very few surgeons, even of his own day, ever gave in their full adhesion to 
the exclusive physiological system as taught and practised by Pott himself; but 
multitudes, especially among the English, adopted in general his views, only 
choosing to place the patients upon their backs rather than upon their sides, and 
laying the limbs flexed over a double inclined plane. To the support of this 
system of Pott's, thus modified, Sir Astley Cooper, C. Bell, John Bell, Earle, 
White, Sharp, and Amesbury, lent the influence of their great names, and its 
triumph, so far as the judgment of British surgeons was concerned, soon became 
complete. 

Fig. 231. 




Amesbury's splint. 

In France, and upon the Continent generally, the reception of this system was 
more slow and reluctant; but Dupuytren, now for once taking ground with his 
great rival, Sir Astley Cooper, adopted almost without qualification these novel 
views. The decision of Dupuytren determined the opinions of a large portion 
of the Continental surgeons ; and had it not been for the early and decisive 
opposition of Desault and Boyer, the great surgeon of St. Bartholomew might 



390 



FRACTURES OF THE FEMUR. 



have continued for a long time to enjoy a triumph upon the Continent, and 
perhaps throughout the world, equal to that which had already been decreed 
to him in Great Britain. On this side of the Atlantic, the practice of Pott, at 
least in so far as it applied to the treatment of fractures of the thigh, never gained 
a distinguished advocate : and but few ever adopted the practice as modified by 
White, Amesbury, Bell, A. Cooper, etc. 

Fig. 232. 




Amesbury's splint applied. 

But whatever may have been the early success of these doctrines, either 
here or elsewhere, it is certain that a strong reaction has taken place, 
and that gradually, in all parts of the world, the opinions of practical 
surgeons have been settling back into their old channel. It would be 
difficult to find to-day, in France or Germany, a dozen distinguished sur- 
geons who adopt universally the flexed position in the treatment of frac- 
tures of the femur; and in England the reaction is, if possible, even more 
complete. 

There have been, then, three grand epochs in the history of the treatment of 
fractures of the thigh. 

First. That in which the straight position was universally adopted, and which 
reaches from the earliest periods to the period of the writings of Pott, or to about 
the middle of the last century. 

Second. The epoch of the flexed position, which, inaugurated by Pott, had 
already begun to decline at the beginning of the present century, and which may 
be said to have been completed within less than one hundred years from the date 
of its first announcement. 

Third. The epoch of the renaissance, or that in which surgeons, by the vote of 
an overwhelming majority, have declared again in favor of the straight position. 
This is the epoch of our own day. 

Although American surgeons have generally adopted the straight 
position in the treatment of fractures of the thigh, yet the form and 



Fig. 233. 




Boyer's splint. 

construction of the splints employed have been greatly varied. The 
simple long splint of Desault, and the more complicated apparatus of 
Boyer (Fig. 233) have each had their advocates; but it is seldom that we 



FRACTURES OF THE SHAFT OF THE FEMUR. 



391 



meet with these, or with any of the other forms of apparatus originally 
employed in foreign countries, without noticing that they have been sub- 
jected to considerable modifications; indeed, most of the straight splints 
as well as double inclined planes in use at present among American sur- 
geons may fairly be regarded as original inventions. 

Nathan Smith, of New Haven; 1 Nathan R. Smith, of Baltimore f Dr. James 
McNaughton, of Albany ; 3 J.T. Hogden, of St. Louis; and Nott, of Mobile, are 

Fig. 234. 




Nathan R. Smith's suspending apparatus, or double inclined plane. 

the only American surgeons of distinguished reputation, and with whose practice 
I am familiar, who have recommended exclusively the double inclined plane. 

Fig. 235. 




Joseph C. Nott's double inclined plane. 

In this apparatus the limb is secured to the splint by vertical pins and leather straps; the 
upper surface of the thigh-splint is carved out a little, to fit the thigh ; the two portions are 
articulated by a joint like that of a carpenter's rule, and this joint may be steadied by a 
horizontal bar underneath. For the rest, the drawing sufficiently explains itself. 

Dr. Nathan R. Smith has introduced a modification of the double-inclined 
plane in what is known as his " anterior splint," and which is intended also as a 
suspending apparatus. I saw it employed a good deal in the treatment of gun- 



1 Amer. Med. Rev., Philadelphia, 1825, vol. ii. p. 355 ; also Medical and Surgical Memoirs 
of Nathan Smith, pp. 129-141. 

2 Med. and Surg. Memoirs, pp. 143-162. See also Greddings, Baltimore Med. and Surg. 
Journ , vol. i. 1833; and Sargent's Minor Surgery, p. 171. 

3 Trans. Amer. Med. Assoc, vol. x. p. 317. Rep. on Deform, after Frac. 



392 



FRACTURES OF THE FEMUR. 



shot fractures of the thigh and leg in our various military hospitals during the 
progress of the civil war, especially at the South. It is my opinion, however, 
that it is more applicable to gunshot fractures of the leg than to those of the 
thigh. The splint, if splint it can be properly called, is simply a frame com- 
posed of stout wire and covered with cloth, which, being suspended above the 
limb, allows the limb to be suspended in turn to it by rollers ; the rollers passing 
around both limb and splint from the foot to the groin. Wire of the size of No. 
10 bougie is usually employed. The length of the splint should be sufficient to 

Fig. 236. 




1ST. R. Smith's anterior splint. 

extend from above the anterior superior spinous process of the ilium to a point 
beyond the toes, the lateral bars being separated about three inches at the top and 
one-quarter of an inch less at the lower extremity. In the case of a broken thigh, 
the upper hook, to which the cord for suspension is to be fastened, ought to be 
nearlyover the seat of fracture, and the lower hook should be placed a little 
above the middle of the leg. 

Fig. 237. 




1ST. R. Smith's anterior splint, applied for a fracture of the thigh. 

The modification of Smith's anterior splint, suggested by Dr. James Palmer, 
United States Navy, will be sufficiently explained by the accompanying wood- 
cut, 1 Fig. 237. 

Hodgen, of St. Louis, Mo., has for many years employed a wire suspension 
splint, which I much prefer to Smith's. The bars of wire are traversed with a 
cotton sacking, upon which the limb is laid. 2 I regret that in earlier editions, 
when referring to this apparatus, I have spoken of it as having been employed 
by Dr. Hodgen in gunshot fractures alone, while in fact it is employed by him 
in all, or nearly all, fractures of the femur. The error came, probably, from the 
circumstance that I had myself seen it used only for gunshot fractures. 

1 Amer. Journ. Med. Sci., 1865,- also, Mechanical Therapeutics, etc., by Philip S. Wales 
M.D., U. S. K, 1867. 

2 Hodgen, Treatise on Military Surgery, by F. H. Hamilton, 1865, p. 411. 



FRACTURES OF THE SHAFT OF THE FEMUR. 393 



Fig. 238. 




Palmer's modification of the anterior splint. 
Fig. 239. 




Hodgen's suspension apparatus. 



394 



FRACTURES OF THE FEMUR. 



Says Dr. Gross : " Many years ago, before I had much experience in this class 
of injuries, I occasionally employed the flexed position, but I soon found that it 
was objectionable, on account of the great difficulty in maintaining an accurate 
apposition to the ends of the fragments. Of late years I have confined myself 
entirely to the use of the straight position, and I have never had any cause to 
regret it. In the adult, I sometimes employ the apparatus of Desault, as modi- 
fied by Physick, but much more frequently one of my own construction, some- 
what upon the principle of that of Dr. Neill, described in the Philadelphia 
Medical Examiner for 1855. I have used it for nearly twenty years, and it has 
generally answered the purpose most admirably in my hands. It consists simply 
of a box for the thigh and leg, with a foot and two crutches, one for the axilla 
and the other for the perineum, to make the requisite extension and counter- 

Fig. 240. 




John Weill's straight thigh-splint. — Extension and counter-extension made at the same time. 

extension. With such an apparatus, an oblique fracture of the thigh can be 
treated with great comfort to the patient, and with the assurances of a good 
limb. In children, I have effected some excellent cures simply by means of a 
sole-leather trough, well padded, and provided with a foot-piece. The great 
objection to the flexed position is the difficulty of keeping the ends of the broken 
bones in apposition ; the upper one having a constant tendency to pass away 
from the inferior. Other objections might be urged against the flexed position, 
but this is quite sufficient to induce me to reject it.'' 1 




Buck's method of extension. 



Dr. Gurdon Buck, of New York, used the pulley, without the long 
side-splint. His perineal band was composed of India-rubber tubing, " of 

1 Trans. Amer. Med. Assoc, vol. x. ; also System of Surgery, by S. D. Gross, 1859, p. 221. 



FRACTURES OF THE SHAFT OF THE FEMUR. 395 

one-inch calibre, two feet in length," stuffed with bran or cotton lamp- 
wick, and covered with canton flannel, which covering may be renewed 
as often as may be necessary ; the extending bands or adhesive plasters 
terminating below the foot in an elastic rubber cord. (Fig. 240.) 

The practice of treating fractures of the thigh, as well as all other fractures of 
the long bones, with the roller alone, and without either lateral splints or ex- 
tending apparatus, first suggested by Radley, has found in this country but one 
distinguished advocate, the late Dr. Dudley, of Lexington, Ky. 1 Nor, with all 
my respect for that truly great surgeon, can I persuade myself that the practice 
is able to accomplish in any degree the indications proposed, nor indeed that it 
is, at least in the hands of inexperienced surgeons, wholly safe. 

It would seem almost superfluous to defend the use of side or coapta- 
tion splints in the treatment of fractures of the shaft of the femur. 

Radley, of England, and Dudley, of Kentucky, treated these fractures without 
side splints and without extension. In 1844 Jobert, at l'Hopital St. Louis, em- 
ployed only extension without side splints. Swinburn, of Albany, rejects side 
splints in all fractures of long bones, relying solely upon extension ; and recently, 
Kronline, of Zurich, has recommended in the treatment of fractures of the thigh 
extension with the weight and pulley, without side splints. 

Against side splints, considered independently of the means by which 
they must necessarily be maintained in position, there can be no possible 
objection. It is only the constriction, and obstruction to the free circu- 
lation caused by the bandages which bind them to the limb, to which any 
objection can be made. The same objection would hold against a roller 
applied directly to the skin, but in a much greater degree, inasmuch as 
it is less easily removed or loosened in case the swelling increases the 
bulk of the limb. This I have always considered a valid objection to the 
roller applied immediately to the skin to this or in any other fracture, 
and as of one of the reasons why the plaster-of-Paris dressings or any 
other form of immovable dressing is relatively unsafe. In a degree, also, 
this objection holds against the continuous roller as a means of holding 
the splints in place. 

If side splints are light, properly adapted to the limb, with no rough 
or unequal bearings ; if they are not bound too tightly to the limb ; if 
they can be loosened or removed without disturbing the limb and are 
not continued beyond the period of their usefulness, they can do no 
harm, while they give important aid in preventing motion at the seat of 
fracture' and in maintaining the fragments in line. This is especially 
true in fractures occurring through the middle poitions of the shaft of 
the femur. If absolute quiet to the limb could be insured during the 
period of union, while asleep and while awake, if the patient had never 
occasion to move his head, shoulders, or nates, the protection usually 
afforded by side splints would be less needed ; but even then the conical- 
shaped limb would find a very unequal and inadequate support upon the 
straight surface of the mattress. In short, the omission to employ side 
splints in most simple fractures of the shaft of the femur would greatly 

1 Amer. Journ. of the Med. Sci., vol. xix. p. 270; Transylvania Journal, April, 1836; 
Boston Med. and Surg. Journ., vol. xxxix. p. 35. 



396 FRACTURES OF THE FEMUR. 

increase the danger of non-union and of deformity, and would therefore 
be inexcusable, 

[Dr. Van Slyck 1 states that he has been very successful in treating fractures of 
the thigh without splints. He resorts to extension and counter-extension, with 
sand-bags to support the foot in position. The extension is by plaster applied 
to the leg in the usual way, but instead of a weight to the foot he fastens the 
rope to the foot of the bed. For counter-extension he uses rubber tubing passed 
over the groin and around the thigh, the ends meeting at the head of the bed, 
where they are fastened as at the foot.] 

The treatment of these and other fractures by plaster-of-Paris, paste, 
starch, or dextrine has been already considered when speaking of the 
treatment of fractures in general. Thus far my experience will not war- 
rant me in recommending the immovable apparatus, as a general plan of 
treatment in fractures of the thigh. 

In order to assure myself as to whether we were able to make longer and 
straighter thighs by the use of the plaster of Paris than by the method of exten- 
sion as employed by myself and others, my later experience has been carefully 
collated, but not selected ; every case in which the opportunity was afforded 
being recorded, and the results being confirmed by my own testimony and the 
testimony of others. Of the cases treated by plaster of Paris, and recorded in 
the accompanying tables, a majority were from the hands of other surgeons, and 
all were hospital cases ; in almost every instance the surgeon treating the case 
having had a large experience in the use of plaster. With very few exceptions, 
the plaster was applied while the patient was under the influence of ether. After 
the plaster was applied most of the patients walked about with crutches ; but 
there were pretty frequent examples in which, for one reason or another, this 
was found impracticable, and the patients remained in bed. The amount of 
shortening has six times exceeded one inch. A considerable bend at the seat of 
fracture has occurred six times; ankylosis of the knee, requiring surgical inter- 
ference, has occurred six times, and in almost all cases it has been more trouble- 
some than it is usually found to be after other plans of treatment ; once gangrene, 
amputation, and death followed, and once abscesses of the leg, paralysis, etc. 

The cases reported as treated without plaster were all treated by myself. The 
method adopted being in the case of adults essentially that which is known as 
Buck's extension, but which I have, as will hereafter be seen, considerably 
modified. In the case of children, the method has been uniformly that which I 
shall hereafter describe in its proper place as the method preferred by me in 
these cases ; permanent extension, such as is used in Buck's apparatus, being 
very seldom employed. Not one of these limbs has presented an excessive 
shortening — one inch being the maximum. Not one is bent at the point of 
fracture. None of the patients had bedsores, or troublesome ankylosis at the 
knee-joint. In one there was delayed union. Case 23 has been measured by 
many of the gentlemen connected with Bellevue, and all agree that the broken 
limb is longer than the other, yet it united promptly, and he walks without a 
halt. We have been unable, thus far, to find any other explanation of the 
increased length except the now well-established fact that the normal lengths 
of thighs and of other long bones are pretty often unequal, and that probably 
this limb was originally longer than the other. The experiments of Reid 2 and 
of others have conclusively shown, I think, that it is impossible, unless at least 
fifty or one hundred pounds were employed in the extension, to stretch the 
muscles beyond their normal length. If a limb after fracture and bony union is 
found longer than its fellow, no doubt it was longer before the fracture. Five 
children and one adult had perfect limbs ; or, if we are permitted to include the 
case in which the limb is lengthened, two adults have recovered with perfect 
limbs. 

1 Boston Med. and Surg Journ., Jan. 29, 1885. 

2 Reid, W. W., Buffalo Med. and Surg. Journ., vol. vii. p. 134, Aug. 1851. 



FKACTURES OF THE SHAFT OF THE FEMUE 



397 



Cases Treated with Plaster-of-Paris, Continuous Roller. 













Amount 






No. 


Age. 


Character of 
, fracture. 


Point of 

fracture. 


Hospital. 


of short- 
ening. 


Deformity. 


Remarks. 




Yrs. 








Inches. 






1 
2 


11 
15 


Simple. 


Middle. 

It 


Bellevue. 
St. Francis. 


i 


| Slightly 
( bent. 


Ankylosis of 
knee 


3 


16 


" 


" 


Park 


l* 




f Ankylosis 


4 


17 


n 


11 


99th Street. 


] 


Much bent. 


< broken up 


5 


12 


f With frac. 
( of legs. 


Below ) 
troch. j 


Park. 


l 


a n 


I under ether. 


6 


16 


Simple. 


" 


Bellevue. 


1 






7 


7 


it 


Middle. 


" 


i 






8 


39 


It 


" 


" 


l 






9 


37 


It 


et 


■ < 


l 






10 


63 


11 


Extracap 


" 


* 






11 


26 


" 


Middle. 


Park. 


1 






12 


24 


It 


a 


<• 


li 






13 


25 


" 


a 


•< 


l 






14 


36 


It 


n 


" 


H 




Ankylosis. 


15 


21 


It 


It 


Bellevue. 


U 




" 


16 


26 


if 


" 


" 


1 






17 


29 


It 


" 


" 


1 






18 


24 


" 


it 


" 


f 




Delayed union. 


19 


39 


" 


" 


99th Street. 


H 






20 


70 


« 


it 


Bellevue. 






No union. 


21 


44 


Compound. 


" 


c 


2 


Bent. 




22 


66 


Simple. 


a 


• « 


1 


Much bent. 


Ankylosis. 


23 


50 


a 


u 


" 


1 


Bent. 




24 


22 


it 


n 


•' 


1 




Ankylosis. 


25 


33 


a 


Extracap. 


x 


t 






26 
27 
28 


23 

27 
46 


it 

« I 


Below 
troch. 
n 

Above 
cond. 


f : 

1 Park. 


Perfect. 

n 

i 




1 Paralysis, ab- 
{ scess, etc. 


29 
30 


51 
23 


Compound. 
Simple. 


Middle. 


Bellevue. 
99th Street. 


i 




f Gangrene, am- 
{ putation, death. 



It will be seen that this table includes two cases in which serious results en- 
sued. In Case 30 gangrene supervened on the third day after the accident, and 
on the second after the dressings were applied ; amputation was made, and the 
t patient died. In Case 27 the plaster was applied on the fifth day after the acci- 
dent (November 13, 1873), and removed twenty days later, when the patient 
found he had no sensation in the limb below the knee ; the leg was also much 
swollen below the knee. Subsequently abscesses formed in the leg, large sloughs 
occurred, and the calcaneum became carious. 

These two constitute the only examples of serious accidents which might pos- 
sibly have been due to the mode of dressing, in the table of 30 cases, which, as 
has already been explained, were recorded without selection ; but they are not 
all which have come under the writer's notice. In one case at Bellevue an enor- 
mous perineal slough was caused by the pressure of the plaster. In addition, 
also, to the case of gangrene and death included in the first of the preceding 
tables, the following have to be recorded : 

L. G., set. 24, fell upon the sidewalk and broke her thigh about six inches 
above the knee-joint. She was carried to Bellevue Hospital, and on the same 
day, under the influence of ether, and with limb extended by pulleys, plaster 
dressings were applied. Twenty-four hours later the toes looked dark, and the 
splint was opened about the foot. On the following morning the house surgeon 
found the limb cold, and sensation greatly impaired. The dressings were at once 
opened freely. Death took place on the third day. 



398 



FRACTURES OF THE FEMUR. 



Cases Treated by myself, by my own and Buck's Methods. 



No. 


Age. 


Character of 
fracture . 


Point of 
fracture. 


Hospital. 


Amount of 
shortening. 


Deformity. 


Remarks. 




Yrs. 








Inches. 






1 


2' 


i 
oimple. 


Middle. 


Bellevue. 


i 

4 


Straight. 




2 


6 


" 


" 


" 


Perfect. 


a 




3 


4 


te 


a 


Private. 


S 


>< 




4 


6 


" 


« 


a 


Perfect. 


a 




5 


10 


" 


(( 


Bellevue. 


it 


a 




6 


9 


(i 


a 


<t 


X 
4 


'( 




7 


15 


e< 


a 


" 


i 


a 




8 


5 


Compound. 


" 


a 


Perfect. 


iS 




9 


18 


Simple. 


a 


a 


a 


" 




10 


33 


" 


a 


« 


1 


a 




11 


20 


a 


a 


a 


H 


a 




12 


50 


tt 


" 


" 


A 


a 




13 


35 


a 


a 


Long Is. C. 


I 


a 




14 


60 


a 


Intracap. 


Park. 


i 


" 




15 


50 


" 


Extraeap. 


a 


1 


i( 




16 


40 


(i 


a 


Bellevue. 


§ 


a 




17 


40 


" 


a 


" 


1 


li 




18 


35 


a 


" 


" 


i 


a 




19 


40 


u 


K 


(i 


h 


a 




20 


60 


" 


" 


Long Is. C. 


I 


" 


Toes everted. 


21 


45 


(i 


a 


Private. 


i 


a 


a a 


22 


70 


" 


Neck. 


" 


i 


a 


a a 


23 


40 


a 


Middle. 


Bellevue. 


Lengthened. 


a 




24 


22 


u 


Above knee 







" 


Delayed union 







C. Gr., set. 62, admitted to Bellevue Jan, 2, 1871, with a fracture of the cervix 
femoris, which had just occurred from a fall on the ice. On the fourth day 
plaster-of-Paris was applied with the aid of ether and pulleys. Two days later 
the record reads: "Patient has a large sore on sacrum, extending almost to the 
loins; splint taken off; extremities cold aud blue; pulse felt with difficulty; 
suffering from some dyspnoea ; lungs emphysematous, and old fracture (?) some- 
where; this P. M. he died." l 

The two following cases deserve to be mentioned in this connection, inasmuch 
as the class of casualties to which they belong are chiefly incidental to the plas- 
ter-of-Paris method. In no other form of dressing have anaesthetics been em- 
ployed so universally : 

J. S. was admitted to Bellevue Hospital with a fracture of the left femur below 
the trochanter. Buck's extension was applied at first, and on the eighteenth 
day the patient was placed under the influence of ether, the pulleys attached, 
and the application of the plaster commenced. The breathing was soon observed 
to be gasping. Ether was withheld a few minutes, when, as the breathing be- 
came regular, it was resumed. Soon after the pupils rapidly dilated, the breath- 
ing ceased, and in a few minutes more, in spite of every effort to resuscitate him, 
death supervened. There is every evidence to sustain the opinion that the ether 
was given carefully and in the usual manner. 2 

In the case of M. 8., No. 11 of the second table, ether was administered for 
the purpose of applying plaster ; and while extension with pulleys was employed, 
and the bandages were being applied, "she suddenly ceased to breathe, and her 
face became purple." By prompt resort to various expedients, including Mar- 
shal Hall's method, Sylvester's method, and electricity, she was rescued. " Dr. 
Figaro thinks her respiration was completely suspended for two or three min- 



i A Comparison of the Eesults of Treatment of 308 Cases of Fracture of the Femur, etc., 
Bellevue Hospital, by Frederick E. Hyde, M.D., New York. New York Med. Journ., 
October, 1874, p. 368. 

2 Death from Ether, by W. B. Dunning, M.D., Acting House Surgeon, Bellevue Hospital. 
New York Med. Record, October 1, 1872. 



FKACTURES OF THE SHAFT OF THE FEMUR. 399 

utes." 1 The attempt to apply plaster was then abandoned, and Buck's extension 
substituted, with the result of giving her a limb shortened only three-eighths of 
an inch. 

A danger in the use of plaster-of-Paris as a dressing for compound 
fracture of the femur has not hitherto been mentioned, namely, that in 
case of a secondary haemorrhage from the femoral artery, it would be 
impossible to compress the artery over the pubes, in Scarpa's space, or 
at any other suitable point, and the patient might die before succor 
could be given. In cases of compound fracture of the femur, from gun- 
shot injuries, such secondary haemorrhages are not very uncommon ; and 
such a haemorrhage has occurred when the femur has been broken very 
obliquely, and thrust through the flesh, and has in its course so contused 
the femoral artery, or has passed so near to it as to have caused a subse- 
quent sloughing of the artery. I do not see how one is to provide for 
such a possible accident, since a fenestra opposite the wound would not 
give space sufficient to secure the bleeding vessel, and a sufficient fenes- 
tra over the groin might so much weaken the splint as to render it of 
little or no value. The accident has occurred, and may occur again ; 
the surgeon ought, therefore, in case he uses the plaster after a compound 
fracture, so far as possible, to provide an opening sufficient for a free 
approach to the upper portion of the femoral artery, in order that pres- 
sure could be applied and the bleeding controlled until the vessel was 
secured. In no other limb than the thigh is this danger so imminent, 
for the reason that nowhere else are the vessels which are liable to rup- 
ture so large. 

It has been almost the constant practice of late, in this country, to employ 
ether and the pulleys while applying the plaster, and this is considered one of 
the great essentials to success. It is proper, then, to put into the account, as 
against this method, the danger from anaesthetics ; and to inquire, perhaps, 
whether the usual danger attending the exhibition of these agents is not in- 
creased by the condition of forced decubitus, and of extension to which the 
patients are subjected while the plaster is being applied. 

Dr. Gibbes, of Columbia, S. C, furnishes the first opportunity yet presented 
to me to observe in the autopsy the result of treatment in a case in which plas- 
ter-of-Paris has been employed according to the method just described. W., set. 
83, weighing 165 pounds, enjoying robust health, fell upon the right hip, caus- 
ing a fracture of the right femur just below the trochanters. Fifteen hours after 
the accident, Dr. Gibbes applied " the plaster-of-Paris dressing after the well- 
known method in vogue for several years past in Bellevue Hospital, my venerable 
patient being kept for some time suspended above the table and fully under 
chloroform." On the fourth day he made an attempt to walk, but the attempt 
was not resumed until about the eighteenth day, after which " he began to walk 
around his room daily." The apparatus was removed on the forty-third day. 
The union was firm, and the limb appeared to be shortened three-quarters of an 
inch, as determined by several careful measurements. On the 29th of June, 
about six months after the accident, he died of apoplexy. At the autopsy it was 
found that the femur was broken just below the trochanters into three fragments. 

In this case there is, according to the measurements made before death, a 
shortening of three-quarters of an inch. An examination of the specimen con- 
vinces me that it is somewhat more ; but however this may be, one thing is 
certain, the limb shortened to the same degree that it would have done if no 
apparatus whatever had been employed. It shortened until the upper end of 
the lower fragment struck and was arrested by the neck. The apparatus enabled 

1 New York Med. Journ., August, 1874, p. 134. 



400 



FRACTURES OF THE FEMUR. 



the patient to walk sooner than he could otherwise have done ; and this is a 
consideration of more importance often in an old man than the length or form 
of the limb, and I doubt whether any other plan would have made the limb in 
this case any longer. 



Fig. 242. 



Fig. 243. 




Dr. Gibbes's case. 

Posterior view. Anterior view. 

A, B, C, three fragments,* d, bony ridge. 



It will be necessary to describe a little more in detail the method of applying 
the plaster-of-Paris in fractures of the thigh. 

A plaster-of-Paris bandage is applied to the foot and leg some hours before 
the complete dressing is made. It is better that this should be done twelve or 
twenty-four hours before, in order that this portion of the apparatus may become 
solid, and not remain liable to be indented, or pressed inward toward the limb 
when extension is applied, and also in order that the surgeon may know by an 
examination of the toes after the lapse of a sufficient time that the dressing is 
not too tight. 

This section of the apparatus should extend from a little above the metatarso- 
phalangeal articulation of the toes to about the junction of the middle and lower 
thirds of the leg. Instead of the soft woollen cloth, which is generally to be 
preferred in the upper part of the limb, we may here lay next to the skin a sheet 
of cotton-batting, and this should be thicker over the instep and above the heel 
than elsewhere. We cannot take too many precautions in protecting the limb 
about the ankle from undue pressure. It will be remembered, also, that while 
at the ankle the splint should be thick, composed of five or six consecutive turns 
of the roller, it may be light upon the foot, and near the upper end of the splint 
upon the leg. While the dressings are being applied, and until they have hard- 
ened, the foot must be held carefully at a right angle with the leg, and in a 
proper line as to inversion or eversion ; but the assistant must take care that he 
does not, with his hand or fingers, indent the plaster. A temporary congestion 
of the toes almost always ensues upon the application of the bandage, but this 
usually subsides within twenty-four hours. If it does not, the bandage is too 
tight, and must be cut open. 

In applying the final dressings on the following day, or when the first dressing 
has become solid, the patient is laid upon a bed composed of two or three mat- 
tresses, or of a sufficient number of folded blankets, his loins, shoulders, and 
head resting upon the bed thus constructed, while his hips, thighs, and legs 
extend beyond the bed. In order to support the lower portion of the body in 



FEACTURES OF THE SHAFT OF THE FEMUR. 



401 



this position a piece of a cotton roller, three inches wide and two yards long, 
having been lubricated with sweet oil, is passed under the pelvis, and tied above 
to a bar supported by a stanchion, as seen in the woodcut (Fig. 244). Various 
methods of supporting the pelvis have been devised, but this is the most simple 
and efficacious. The piece of bandage is directed to be softened with oil, in 
order that it may be easily withdrawn when the dressing is hard ; but if it has 
not formed a cord this may not be necessary, and it is sometimes cut off and left 
inclosed with the splint. 

Fig. 244. 




Extension during application, of plaster of Paris. 



The iron stanchion, wrapped with woollen cloth, is now brought against the 
perineum,, and the pulleys made fast to the foot by a noose of cotton bandage. 
Moderate extension is made sufficient to support and steady the limb, but not 
sufficient to overcome the shortening. 



Fig. 245. 




Extension continued until the plaster is hard 



The surgeon now wraps the limb, including the pelvis, thigh, and leg, down 
to the first splint, with soft but coarse woollen cloth, cutting out portions here 
and there, and fitting it smoothly to all the irregularities of surface, and stitching 

26 



402 FRACTURES OF THE FEMUR. 

it loosely, when it is in place, over the region of the tuberosity of the ischium 
and perineum. Where the splint is liable to make undue pressure, two or three 
thicknesses of cloth may be placed, or cotton-batting may be used instead. 

Everything being ready, the assistant places the patient completely under the 
influence of an anaesthetic, and then extension is made with the pulleys until 
the limb is restored, if possible, to the same length as the other. The bandages, 
filled with dry plaster, and previously soaked a few minutes in water, are then 
applied from below upward, including, finally, the pelvis as high as the loins. 
At no point must they be drawn tightly, but only with sufficient firmness to 
insure their accurate adaptation to the limb. Three, four, or five thicknesses 
are required, according to the size of the limb or the age of the patient. In 
front of the groin, where the splint is most liable to become broken when the 
patient gets up, there should be laid two or three strips of binders board, or 
narrow metal strips, tin or zinc. After each successive layer is applied, the sur- 
geon will sprinkle a little dry powder upon the surface, and smooth it over with 
his hand previously dipped in water, As soon as the plaster is hard, usually 
within twenty or thirty minutes, the suspending apparatus is removed, and the 
patient placed in bed. 

The surgeons who omit to include the foot and ankle in the plaster splint do 
not, I think, avail themselves of the most important and most reliable means of 
making the little extension that can be made permanently in this form of dress- 
ing. When the limb shrinks, the condyles of the femur and the calf of the leg 
offer very imperfect or no resistance to the action of the muscles of the thigh, 
and extension is completely lost. Let it be understood, also, that the author 
does not recommend that the perineum shall be made the point of counter- 
extension ; and in this he is sustained by the majority of those who have used 
this dressing ; and the skrinkage of the muscles of the thigh, which soon ensues, 
renders it equally impossible, ordinarily, to maintain permanently, against the 
only slightly conical surface of the upper portion of the thigh, any effective 
counter-extension. 

The patient can, in most cases, leave his bed by the third or fourth day after 
the splint is applied. If he keeps out of bed the limb will not shrink as much, 
and the necessity for readjustment will less often arise. But he cannot remain 
in the erect position all the time, and at the best there will be, as experience 
shows, opportunity enough for the limb to shrink, and for the apparatus to 
become loose. In case it becomes loose it cannot be refitted by cutting out a 
portion and folding the splint in again, since it is too inflexible, and will not be 
made to bear upon the same points as before. At Bellevue, when a plaster 
dressing becomes loose it is always removed and a new one applied in the same 
manner as at first. 

[The dangers of the injudicious employment of plaster-of-Paris dressings have 
not been too emphatically stated in these pages, but it should not be inferred that 
this dressing may not be used safely by a prudent surgeon. It is a method of 
treatment of fractures of undoubted value, and every surgeon should familiarize 
himself with its use.] 

Finally, having considered somewhat at length the leading plans of 
treatment which have, from time to time, been suggested and employed 
by our best surgeons both at home and abroad, I desire to describe in 
greater detail those methods and forms of apparatus which my own 
experience has taught me to prefer. 

As to posture, my opinions are in accord with the opinions of a vast 
majority of the most experienced surgeons of the present day. The 
straight position will, on the average, give the best results. Careful 
measurements made by myself in several hundreds of cases, a portion 
of which have been published in my statistical tables. 1 have demonstrated 
that the average shortening of the limb is greater afier any method of 

1 Fracture Tables, by F. H. Hamilton, 1853. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



403 



treatment in which the flexed position is employed, than after treatment 
with extension in the straight position. These same carefully recorded 
observations, and my later observations, have also shown that the flexed 
position, contrary to the reiterated statements of most of its advocates, is 
more apt to entail angular deformity. Fig. 246 is a fair illustration of 
what I have seen occur more than once when the flexed position has been 
adopted ; a condition which is impossible when proper extension is em- 
ployed in the straight position. There are a few who, rejecting the flexed 
position in fractures of the middle of the shaft, still declare for this posi- 
tion a preference when the fracture occurs just below the trochanters, and 
in the case of fractures at the base of the condyles. 



Fig. 246. 



Fig. 24< 





Badiy united fracture of the femur ; treated 
without permanent extension. 



Fracture of femur just below trochanter 
minor. 



According to Malgaigne, who has devoted especial study to this sub- 
ject, there is no satisfactory evidence in favor of the flexed position when 
the fracture occurs below the trochauters. It is not directly forward 
but forward and outward, that the lower 'end of the upper fragment is 
carried by the action of the psoas nmgnus and iliacus internus ; so that 
in order to meet the supposed indication it would be necessary to carry 
the lower part of the limb outward also, a position which would certainlv 
be found inconvenient, if not actually impractiable, in the majority of 
cases. Nor can the tendency of the upper fragment to advance in the 
forward direction, and consequently to separate from the lower, be met 



404 FRACTURES OF THE FEMUR. 

effectually by posture alone, unless the thigh is completely flexed upon 
the body. Indeed, it is apparent that the position of moderate flexion 
will rather favor the action of those muscles which are supposed to be 
chiefly responsible for the displacement. When the thigh is extended 
upon the body, the psoas magnus and iliacus internus are acting in the 
direction of, and merely parallel to, the axis Of the femur, and conse- 
quently to a disadvantage ; but when the limb is lifted, their action is 
more nearly at a right angle with the shaft, and their ability to displace 
the fragment is greatly increased. 

Moreover, it ought to be understood that broken bones are seldom or 
never displaced or separated, in the same manner they would be if they 
were not surrounded with many other structures which have suffered little 
or no disruption ; they pass each other, but do not separate widely, being 
held together by shreds of periosteum, muscles, tendons, ligaments, etc. 
The same happens when this bone is broken just below the trochanters ; 
the upper fragment lies always, or almost always, in immediate contact 
with the lower, and whatever force is brought to bear upon the lower 
fragment more or less directly influences the upper ; we can then by 
extension applied to the leg, draw down not only the lower fragment, 
but we can drag into line the upper fragment. No doubt in this attempt 
we shall meet with some resistance from the muscles above named ; but 
experience has always shown that even moderate extension, applied 
steadily and without interruption, seldom or never fails to overcome, in 
a great measure, the resistance of the most powerful muscles. We con- 
stantly avail ourselves of this principle in overcoming the abnormal con- 
traction of muscles in connection with diseased joints, in the reduction 
of old dislocations, and in many other ways. 

Whatever the advocates of flexion in fractures of the femur may say 
to the contrary, they are never able in this position to employ effective 
extension and counter-extension. A careful examination of all the 
double-inclined planes which have been devised, it appears to me, ought 
to convince any experienced observer that such is the fact. Whatever 
other excellences they may possess, this does not belong to them. But 
extension is, of all the indications of treatment, that which is of the 
greatest importance in nearly all fractures of the thigh, and no less 
important in the upper third than in the lower. Indeed, it is of more 
importance in case of a fracture through the upper than in the case of a 
fracture through the lower third, since, as my measurements have shown, 
the higher the point of fracture the greater is the tendency to shorten, 
in consequence of the action of those powerful muscles which, arising 
above, have their insertions into the lower fragment. 

In the case of all those doubled-inclined planes where the body rests 
upon a bed, there can be no counter-extension except the weight of the 
pelvis and its contents. It will not do to fasten the pelvis to the bed by 
bands, as every one who chose to make the experiment might soon learn ; 
nor will the groin tolerate the pressure of counter-extending splints or 
bands. These things have been tried in a thousand ways, and aban- 
doned. The weight of the pelvis alone, not of the entire body, is the 
only counter-extending force which can be made available in these forms 
of apparatus, and this is wholly insufficient. In Nathan R. Smith's 



FRACTURES OF THE SHAFT OF THE FEMUR. 



405 



anterior suspension splint, not even the weight of the pelvis is employed 
as a means of counter-extension, the pelvis being secured to the splint 
by rollers, equally with the thigh and leg, and there is no possible chance 
for extension or counter-extension, 

[It is still maintained, by many competent surgeons, that the double-inclined 
plane is best adapted to the treatment of fractures just below the trochanter. If 
it is used the surgeon must secure extension by the fixation of the leg to the 
distal portion, and counter-extension by the weight of the hips resting against 
the lower end of the proximal portion, but not supported by it. The thigh piece 
should, therefore, be slightly longer than the thigh to secure proper counter- 
extension of the upper fragment, the lower fragment being fixed by the leg 
and knee. A very simple but useful double-inclined plane is that known as 
Esmarch's.] 

Fig. 248. 




Double-inclined plane. (Esmarch.) 

After all, I prefer to leave this question to the verdict of experience, and 
happily this seems to be conclusive, if we may accept the almost unanimous 
testimony of those surgeons who have enjoyed the largest hospital practice. In 
my own experience the ordinary double-inclined planes have constantly given 
the worst results both in regard to length and lateral displacement ; they are the 
most difficult to manage, and are the most fatiguing to the patients. Nathan R. 
Smith's suspending apparatus permits the limb to shorten indefinitely ; and it 
affords inadequate support along the centre of the shaft, in consequence of which 
the limb is apt to unite with a backward curvature or angle. In some gunshot 
fractures treated by this apparatus this posterior curve or angle has been exces- 
sive. Even the old methods of extension were preferable to flexion ; but they 
had always two serious drawbacks. First, in the excoriations and ulcerations 
incident to the application of extending bands or gaiters, or whatever else was 
employed for this purpose. Again and again I have seen ulceration of the instep, 
of the integuments above the heel, and of other parts of the foot and ankle, from 
extending bands. And, second, from similar excoriations, ulcerations, and deep 
sloughs about the groin and perineum, caused by the counter-extending band. 
It is true these accidents did not occur often, and sometimes they were due 
wholly to negligence; but, in order to avoid them,- we were compelled to limit 
very much the amount of extension, and to exercise unceasing vigilance. 

[Commingor, of Indianapolis, Ind., a strong advocate of plaster-of-Paris in the 
treatment of fractures of the thigh, 1 does not approve of the straight position, 
but prefers the flexed. He also discards the weight and pulley extension. His 
method of treatment consists in bringing the bones into apposition at once, then 
applying the plaster-of-Paris, the limb being one-third flexed at the knee and hip. 
When the plaster becomes hard there is no necessity for the weight, as the 
flexures of the limb prevent any possible shortening.] 

Our first great step of progress in the treatment of fractures of the 
thigh — first in importance, but not in order of discovery — consists in 
having secured counter- extension by the weight of the body alone, and 



1 American Practitioner, 1885. 



406 FRACTURES OF THE FEMUR. 

this is accomplished by simply elevating the foot of the bed from four 
to six inches. . 

I have not used a perineal band, except in cases of children, for twenty years ; 
and, in case of children, the weight of the body is still my chief reliance. The 
first to suggest and practise this was Dr. James L. Vaningen, of Schenectady, 
New York. 1 

The second step was the employment of the weight and pulley as a 
means of extension. 

This method of making extension was known to Hildanus, in the 16th cen- 
tury, although it seems to have passed very much into disuse until recently 
revived by American surgeons. 2 John Bell, in his Principles of Surgery, pub- 
lished at Edinburgh in 1801, speaking of a method described by Hildanus, says : 
" But surgeons did at last fall upon a method which absolutely insured the per- 
manent extension. For being wearied with this perpetual turning of screws to 
tighten the bands around the ankle, they at last most happily thought of putting 
a pulley to the foot of the bed and hanging a good jack-stone to the heel. I 
have (in next page) drawn the bed, the surcingle or horse-girth for the body, 
and the jack-stone of Hildanus for hanging to the heel.'' In the above descrip- 
tion we see a full recognition of the value of the pulley and weight, but the 
body was prevented from descending by being tied to the bed, and the extension 
was made by a garter. We need not be surprised, therefore, that the pulley and 
weight under these disadvantages were soon laid aside and forgotten. Guy de 
Chauliac, Suetin, and Nathan Smith, according to Malgaigne, 3 employed occa- 
sionally the pulley and weight. Boyer says the practice is very ancient. Dr. 
W. C. Daniell, of Savannah, Georgia, treated a case in this manner in 1819, and 
again in 1824, the latter of which he published. The ordinary perineal band 
and a garter were used for counter-extension and extension. 4 In 1854, L. A. 
Dugas, of Savannah, Georgia, published an account of the method employed 
by himself, with an illustration. 5 He used a piece of bandage as his means of 
applying extension ; but he omitted the perineal band, which had not been done 
by Buck when he first made public his own method. Dugas relied upon the 
weight of the body to make counter-extension, saying that " the resistance of 
the patient's body will effect counter-extension ;" a statement which later experi- 
ence has shown to be not correct, unless, as first recommended by Vaningen, 
the foot of the bedstead is somewhat raised. 

The third great step of improvement, and that which alone makes 
adequate extension, in most cases, possible, was the substitution of adhe- 
sive strips, laid along the whole length of each side of the leg, in place 
of the gaiter. 

Of this, also, we are no longer permitted to speak as a novelty, the researches 
of Dr. Martin, already referred to, having brought to light the following para- 
graph in the works of Dr. Gooch : "To answer the same purpose, I have con- 
fined one end of a strong strip of sticking plaster, of a suitable length and 
breadth, under a circular piece of the same, about the middle of the side of the 
foot, carrying it over the heel, up the leg, and confining the other end above the 
calf with another circular plaster, first, gradually bring down the muscul. gas- 
trocnem. as far as they will readily yield ; giving the limb, at the same time, the 
position described in my treatise on wounds. On the like occasion, I have also 
fixed one strap by the circular about the foot, and another by that above the calf 
of the leg, passing the one through a slit in the other, and using them as the 

1 Vaningen, Trans. Amer. Med. Assoc, 1857. pp. 436-7. 

2 Martin, N". C. Med. Journ., Feb. 1878. 3 Malgaigne. op. cit., p. 239. 
i Daniell, Amer. Journ. Med. Sci., vol. iv. p. 330. 

5 Dugas, Southern Med. and Surg. Journ., Feb. 1844, p. 69. 



FRACTURES OF THE SHAFT OF THE FEMUR. 407 

uniting bandages ; but then two more circulars are requisite to confine the other 
ends of the longitudinal straps securely." 1 

This also, like extension by a pulley and weight, seems to have been forgotten 
until revived by some American surgeons. The first allusion I find to it in 
recent literature is by Dr. F. W. Sargent, of Philadelphia, in 1848, who says he 
derived the suggestion from Dr. E. Wallace, of Philadelphia, by whom they 
were used successfully while he was the Resident Surgeon of the Pennsylvania 
Hospital. Both of these gentlemen used long strips of adhesive plaster, of an 
inch or more in width, carrying them spirally down the leg from a point about 
midway between the foot and knee, after which they were, in some cases, made 
secure with rollers. 2 The same method is described as being recommended by 
Dr. Josiah Crosby, of New Hampshire, the only difference being that he carried 
the adhesive plaster as high as the knee. 3 In this notice of Dr. Crosby's plan, 
the editor remarks that Dr. Sargent had in his Minor Surgery described essen- 
tially the same, as being first practised by Dr. Wallace. Vaningen suggested 
the same in connection with the elevation of the foot of the bed, in 1857. Dr. 
Buck spoke of it in his communication to the Academy of Medicine in 1861. 
Of the claims instituted for Dr. Mosely, of New Hampshire, who says his use 
of these strips dates back to 1840, and the like claims of Gross, Swift, Ennis, 
and others, we can only say they were unfortunate in not earlier giving their 
views and practice to the public. 

Finally, it is by the combination of these three essential principles 
with the short side-splints and one long side-splint, which shall reach 
from near the axilla to beyond the foot, to prevent the outward bowing 
of the thigh and to prevent eversion of the leg, that the superiority of 
extension in the straight position can alone be demonstrated. The long 
outside splint, which I have myself added to the apparel, is only second 
in point of importance to either of the others, and that whether the frac- 
ture be in the neck or the shaft, in children or in adults. In children, 
however, it is supplied by the double splint. 

With regard to fracture beds, which, when surgeons adopted the flexed 
position in the treatment of fractures of the thigh, were often very useful 
and sometimes necessary, I must say that, in the treatment of these frac- 
tures in the extended position, they are not needed. If the bed is suf- 
ficiently long and the mattress is smooth, firm, and even, nothing more is 
required. Properly shaped bed-pans can always be used without dis- 
turbing the limb, and the arrangements for changing the position of the 
limb are not only useless, but such changes are actually injurious. In 
certain complicated cases of fracture of either the thigh, leg, or foot, 
adjustable or movable " invalid " beds maybe needed, when extension 
is not to be attempted. 

As invalid beds, the best known and most ingenious American contrivances 
are those invented by Jenks, 4 Daniels, the Burges, Addinell Hewson, of Phila- 
delphia, 5 J. Phea Barton, B. H. Coates, of the same city, 6 and J. Crosby, of Man- 
chester, N. H. 7 

1 " Medical and Chirurgical Observations as an Appendix to a former Publication, by 
Benjamin Gooch, Surgeon, London, printed for G. Robinson, in Pater Foster Row, and 
R. Beatniffe, in Norwich. " No date, but about 1771. N. C. Med. Journ., Jan. 1878, 
Martin. 

2 Minor Surgery, by F. W. Sargent, M.D., Lea & Blanchard, Philadelphia, 1848. 

3 Crosby, Trans. Amer. Med. Assoc, 1850, vol. iii. p. 383. 

* Jenks, Gibson's Surgery ; also the 5th ed. of this treatise, Fig. 185, p. 445. 

5 Hewson, Amer. Journ. Med. Sci., July, 1858, p. 191. 

6 Eclectic Repertory, 5th and 9th vols. 

7 Crosby, Treatise on Military Surgery, by Frank H. Hamilton, 1865, p. 413. 



408 



FRACTURES OF THE FEMUR. 



In my earlier practice I have had constructed a simple frame, covered 
with a stout canvas sacking, having a hole at a point corresponding with 
the position of the nates, and this I have laid directly upon a common 




E. Daniel's invalid bed 



four-post bedstead. A mattress and one or two quilts must be placed 
upon the boards of the bedstead underneath the sacking, and a sheet or 
two above the sacking, upon which last the patient is to be laid. In 
arranging the linen underneath the patient, the most convenient plan is, 




fffC^T^f 1 ^) 



Burge's apparatus applied; this is a very servicable appliance as it comprises both a bed 
and a splint, and enables the patient to lie or sit without pressure in the groin. 

instead of using only one sheet, which will require that a hole shall be 
made in it corresponding to the hole in the sacking, to employ two sheets, 
and, doubling them separately, to bring the folded margin of each from 
above and from below to the centre of the opening. When the patient 
has occasion to use the bed- pan, it is only necessary that two or four 
persons should lift this frame, and place under each corner a block about 

1 See Figs. 1 86 and 189 ot 5th edition of this treatise. 



FRACTURES OF THE SHAFT OF THE FEMUR, 



409 



one foot in height, or it may be raised by a pulley and ropes suspended 
from the ceiling. 

Fig. 251. 




Crosby's invalid bed, open. 

The bed is movable, and can be run out from under the patient and changed. It is then 
run back, the hooks B being made fast to the catches A. By turning a crank at C, the rail 
D is revolved, which winds up a strap passing over tbe pulley G-, and the bed is raised to 
its position, thus taking off the weight of the patient from the bands by which he was tem- 
porarily suspended. 

My usual practice now, in a private house, is to remove the foot-board and 
lengthen the bed by boards laid longitudinally, and projecting one or two feet 
beyond the bottom rail. This furnishes a firm support for the mattress. Some- 
times, of course, it will be fouud necessary to lengthen the bed. No bole is made 
in the flooring of the bed or of the mattress, to provide for faecal evacuations. 



A very comfortable bed, especially for children, can sometimes 
from a cot. But it will be necessary always to nail a piece 
firmly across the top and bottom of the bedstead when the 
sacking is at its utmost tension, in order to prevent the side 
rails from falling together. The top board must be nailed on 
vertically, like an ordinary head-board, so as to prevent the 
pillows from falling off, but the bottom piece, at least one foot 
wide, should be laid horizontally to support and steady the appa- 
ratus as it extends beyond the foot. ( 

Having had occasion to assist the late Dr. Treat in the management 
of a fracture of the thigh in the case of a little girl not quite three 
years old, I was struck with the simplicity and completeness of an 
arrangement which he had made to prevent the bed and the dressings 
from becoming soiled with the urine. It was only to leave directly 
underneath the nates a complete opening through to the floor for the 
escape of the urine, and to protect the margins of the sacking and 
sheets, which came nearly together at the opening, with pieces of 
oiled cloth folded upon themselves. It was found that not only the 
bed was in this way kept dry, but the dressings also; it being now 
observed that the dressings had become wet heretofore by soaking up 
the moisture from the bed, rather than by the direct fall of the urine 
upon them. 



be made 
of board 

Fig.}252. 



Standard. 



Having prepared the bed for the reception of the patient, and 
elevated its lower end about four inches by placing blocks underneath the 
footposts, the following additional preparations should be made before we 



410 



FRACTURES OF THE FEMUR. 



proceed to reduce the fracture and dress the limb. There should be pro- 
vided a piece of board of the requisite length and breadth, furnished 
with a slot to receive the pulley, and called the " standard," a small iron 
rod, a pulley, a yard of rope, and a vessel or bag to receive the weights. 
The slot should have sufficient length, and the standard should be perfo- 
rated in the direction of its breadth at short distances, to enable the sur- 
geon to elevate or depress the pulley, as may be required. In case a 
metallic pulley cannot be obtained, a spool will answer as a tolerable sub- 
stitute. We now employ generally, at Bellevue, an iron upright rod, 
with a pulley affixed, and which is made fast to the iron frame of the 
bedstead with two iron clamps, secured in place by screws. They may 
be found at the shops of any of our instrument-makers. A pulley, 
mounted with a screw, may be sometimes substituted, the screw being 
attached to the foot-board. (Fig. 253.) 

The adhesive plaster which I have generally used both in private and 
hospital practice is that which is usually found in drug-stores, spread 
upon linen ; but some prefer the plaster spread upon jeans or canton 
flannel as being stronger. I cannot, however, appreciate the advantage, 
since the ordinary plaster seldom gives way when properly applied. 



Fig. 253. 



Fig. 254. 





Iron upright and weight. 
(From Tiemann.) 



Foot-piece. 



A thin block or piece of board, called the "foot-piece," is to be pro- 
vided, perforated in the centre to receive the cord, and of sufficient 
length to prevent the adhesive strips or" extension bands " from press- 
ing upon the malleoli. An average size for the foot-piece in the case of 
an adult is about three inches and three-quarters in length, by two and 
a half in breadth. The adhesive plaster may be cut in the shape shown 
in the illustration (Fig. 255) ; five and a half inches wide in the centre, 
and two and a half inches wide at the narrowest point, and gradually 
widening again toward each extremity to four inches ; the narrower por- 
tions being slit down two-thirds of their length. For an adult we gener- 



FRACTUEES OF THE SHAFT OF THE FEMUR. 411 

ally require a strip of about four feet and eight inches in length, namely, 
sixteen inches for the central and widest portion, and twenty inches for 
each extremity. The shoulders of the central portion are cut as repre- 
sented, in order that when folded upon the foot-piece and upon itself it 
may reinforce the lateral bands at their weakest points. 

[It is quite unnecessary to shape the strips in the manner here directed. They 
may be cut of equal width the whole length, about three inches for an adult limb 
will meet every indication. The foot-piece to w r hich the cord is attached may 
be strengthened by an additional strip applied with the plaster to the plaster.] 

The lateral or side-splints may be made of thick pieces of gum- shellac 
cloth, of stout leather cut and moulded to the limb, or of thin pieces of 
board covered with cotton cloth and stuffed on the sides next to the skin 
with cotton-batting to fit all the inequalities of the limb. Of these 
several materials gum-shellac cloth is much the best. It is thin, light, 
firm, and after immersion in hot water can be sufficiently moulded to the 
contour of the thigh. The cotton cloth must be stitched over the splints 
like a sac, but left open at the ends until the padding is properly ad- 
justed. Loose cotton-batting always becomes displaced. Four splints 
are generally required : one for the anterior surface, extending from the 
groin below the anterior inferior spinous process of the ilium to within 
half an inch of the patella ; one for the posterior surface, extending from 
the tuberosity of the ischium to a point six or eight inches below the 

Fig. 255. 




m 



Extension-band and foot-piece. 




knee ; one for the inside, extending from near the perineum to the inner 
condyle ; and one for the outside extending from above the trochanter 
major to the outer condyle. These splints ought to encircle the limb 
almost completely, only leaving an interval of from half an inch to one 
inch between each of the adjacent splints. The outer and inner splints 
may be extended below the knee when the fracture is low down ; but in 
that case they must be carefully fitted to the irregularities of the con- 
dyles. The posterior splint is the most important of them all. It should 
be wider and much longer than either of the other splints, and it must 
be fitted with great accuracy to the back of the thigh, ham, and upper 

Fig. 256. 




s 



Same, folded and ready for use. 



part of the leg. It is important also to cover this with a sack of cotton 
cloth so that it may be stitched to the centre of the bands, which are to 
inclose all the splints. If this is not done, it is very liable to become 
displaced. 



412 FRACTUEES OF THE FEMUR. 

A long side-splint must now be prepared, long enough to extend from 
about four inches below the axilla to five inches below the heel ; four 
and a half inches wide, by half an inch in thickness, and provided with 
a cross-piece at the lower end, two feet long by three inches wide and 
half an inch thick. The purpose of this splint is not to make extension, 
but to prevent the femur from becoming bent outward at the seat of 
fracture; which is accomplished more certainly by this splint than by 
the short splints, inasmuch as it keeps the whole body, including the 
upper part of the femur, in a straight line. Its purpose is also to pre- 
vent eversion of the foot, which purpose is never accomplished effectively 
by junks or by any other method I have yet seen adopted. It is to be 
employed in all fractures of the thigh, including fractures of the neck. 
The inner surface of this long splint must be padded throughout its whole 
length, and thus fitted accurately to the sides of the body and limb. 

[Dr. A. D. Smith, 1 of Philadelphia, recommends the following splint to pre- 
vent eversion of the foot : A posterior splint eighteen inches long, shaped some- 
what like the leg, with a hinged foot-piece held in position by hooks at the 
base ; at the upper end two pieces of leather, sufficiently large to embrace the 
leg, are fastened, having eyelet holes, and laces at their free border; two similar 
pieces are fastened to the foot-board to embrace the instep and base of the toes ; 
on the under surface, just beyond the foot-board, is fixed a strip of wood twenty 
inches long and one and a half to two inches wide, one end held by a bolt on 
which it may revolve, the other free.] 

Four or six strips of cotton cloth, each two inches wide by one yard 
in length, are stitched by their centres to the back of the posterior splint, 
and these are laid upon the bed in position to receive the limb. Supplied 
with rollers, several additional strips of bandage, and cotton-batting, we 
are now ready to reduce and dress the fracture. 

The patient being placed in position upon the bed, one assistant seizes 
the limb by the knee, and a second by the foot, drawing upon it firmly 
and steadily, at the same moment lifting it from the bed so as to render 
it more accessible; while the surgeon lays the extremities of the exten- 
sion strip upon each side of the leg, with the centre, containing the foot- 
piece and the rope, about one inch below the sole of the foot. With a 
muslin roller, inclosing the limb from near the metatarso- phalangeal 
articulation to the tuberosity of the tibia, the adhesive strips are held in 
place. As a rule, and especially in the case of women, and of persons 
of a delicate lax fibre, it is well to lay against the tendo Achillis, and 
over the instep, a little cotton-batting before applying the roller. In 
some cases I am in the habit of applying a thin sheet of cotton-wadding 
over the whole surface of the limb. Any excess of the bands at the 
upper end is disposed of by turning the ends down, and inclosing them 
in a few additional turns of the roller. As soon as the application of 
the adhesive strip and roller is completed, the weight may be adjusted, 
and extension applied. The amount of extension required for adults 
will vary from eighteen to twenty-three pounds. In a large proportion 
of cases, twenty or twenty-one pounds will be borne without complaint ; 
and the ability of the patient to tolerate the extension, alone limits the 

1 Therapeutic Gazette, Nov. 15, 1888. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



413 



amount. Occasionally, even a few pounds, when first applied, cause pain 
in the ligaments about the knee-joint ; but in a few hours the amount 
may be increased. It is better to apply eighteen or twenty pounds at 
once, if it can be borne. Lifting the knee slightly by a pad placed 
underneath will often relieve the pain caused by the extension. 

Fig. 257. 




Mode of applying adhesive plaster. 
(When the dressings are completed, the limb is to rest on the bed.) 

[It is better to have the plaster strips extend above the knee, and nearly to 
the point- of fracture. If they are applied altogether below the knee, the joint 
will be subjected to an unnecessary strain, which may cause a certain degree of 
weakness of the fibrous structures.] 

Sometimes, in the case of very muscular patients, and where the primary 
shortening is considerable, I believe we make a positive and permanent gain if 
we place the patient under the influence of chloroform for a few minutes when 
the weight is first applied. In these cases, as in dislocations, I generally prefer 
chloroform to ether, for the reason that the patient is less liable to muscular con- 
tractions when he is passing under the influence of the anaesthetic. 

Extension being effected, and the patient already resting upon the 
posterior coaptation splint, the three other side-splints are applied, and 
the whole four secured in place by the four or six transverse bands 
already described as attached to the posterior splint ; the bands being 
tied over the front splint firmly. 

It remains only to lay the long splint beside the body, and to secure 
it in place by separate strips of bandage. Three strips for the leg, one 
broad strip for the pelvis, and one for the chest, are all that are required. 
The leg strips may be drawn pretty firmly to prevent all outward rota- 
tion of the limb. The pelvic band also ought to be tight enough to 
insure the constant contact of the pelvis with the long splint ; but the 
thoracic band may be rather loose, as its function in this respect is not so 
important. One broad band may be substituted for the two latter, which 



414 



FRACTURES OF THE FEMUR. 



should be sewed to the cover of the long splints to prevent its becoming 
displaced. In the drawing (Fig. 258), narrow strips inclose the thigh 
and long splint, but I often omit them as being unnecessary ; indeed, it 
is better sometimes to omit them when the fracture is high up, lest they 
should hold the lower fragment out, when the pelvis was not firmly 
secured to the long splint ; in which case the other fragment might incline 
in the opposite direction, causing thus a bowing out at the point of frac- 
ture. The patient's pillow must rest under the head alone, in order that 
the whole weight of the body, from the shoulders down, may be em- 
ployed as a means of counter-extension. Omission of this important 
precept will sometimes permit the body of the patient to descend toward 
the foot of the bed, even when the foot of the bedstead is raised. During 
the first four or five weeks the patients should not be allowed to rise or 
to sit up in bed. 

Fig. 258. 




Author's dressings for fracture of shaft of femur, complete. 
(The long splint extends nearly to the axilla.) 



It is an error to suppose that such restraint is irksome. In my experience, no 
patient has ever complained of it ; and I have no doubt that such movements 
increase the danger of non-union ; a misfortune which has never happened 
when a patient has been under my treatment from the first to the last. [ have, 
however, seen several cases of non-union, or of delayed union, in the practice 
of other surgeons, which I attributed to the patient having been permitted to 
rise in bed. For this reason, also, I reject all modes of treatment which are 
intended to permit these motions of the body. 

In order to evacuate the bowels, the patient may draw up the sound 
limb, when a properly constructed bed-pan is easily placed under the 
nates. This occasions no disturbance to the fracture. From the time of 
the first dressing the patient should be seen daily, and the coaptation 
splints loosened or tightened from time to time, as may seem necessary. 
To open the limb, and even to remove temporarily all the coaptation 
splints except the posterior one, is harmless, and it is often a source of 
comfort to the patient. Ordinarily it is not necessary or prudent to dis- 
turb the extension until the union is completed. The usual time required 
for consolidation in the case of an adult is from six to eight weeks ; but 



FRACTURES OF THE SHAFT OF THE FEMUR, 



415 



if the bone feels pretty firm at the end of four weeks, the extension may 
be a little relaxed. When at length the patient is permitted to leave his 
bed, a pair of crutches is indispensable ; and during the following two 
months but little weight should be borne upon the limb. 

[Volkmann's sliding rest is a very useful appliance, as it allows the leg to slide 
on the frame during extension without any friction (Fig. 259).] 

Fig. 259. 




Volkmann's sliding rest. 

Fractures of the thigh in children have generally been found more 
difficult to manage than fractures of the same bone in the adult, owing 
chiefly to the shortness and softness of the limb, the delicacy of the skin, 
its liability to become excoriated or to become soiled, and the restlessness 
of the patient. I have tried nearly all forms of apparatus in these cases, 
including double-inclined planes, boxes, single long splints, etc., and the 
result of my experience is that they are all inefficient ; and for some 
years I have employed a mode of dressing, partly my own and partly the 
suggestion of others, but of which I am able to say that it never disap- 
points me in the result obtained ; while it is simple, easy of management, 
and comfortable to the little patients. 

Extension by means of adhesive plaster and a weight employed in the 
same manner as in adults, constitutes a valuable aid in many cases ; but 
I cannot say that it is indispensable, since, with children under five or 
seven years, the fractures are pretty often so nearly transverse that, when 
once reduced and well supported by lateral splints, union without shorten- 
ing may generally be expected; but these results become less and less 
frequent as we advance toward adult life. It is safe and proper, accord- 
ing to my experience, to employ in any case extension, somewhat accord- 



416 



FRACTURES OF THE FEMUR. 



ing to the following rule. One pound for a child one year old, two for 
a child two years old, and so on, adding one pound for every year up 
to the twentieth. Of much more consequence, however, is it to con- 
fine, at the same time, both limbs, for as long as one is at liberty it is 
almost impossible to secure any degree of quiet. It is of equal im- 
portance, in my opinion, to give to the limbs an extended rather than a 
flexed position. 

Fig. 260. 





Author's splint for fracture of the femur in children. 

My plan of treatment, therefore, in the case of children, is in all 
essential respects the same as in adults, except that instead of one long 
side-splint, I employ two. The accompanying illustrations will explain 
more fully my meaning. Two* long side-splints connected by a cross- 
piece at the lower ends, and reaching upward to near the axillae, sepa- 
rated a little more widely below than above, so as to render the perineum 



Fig. 261. 




Author's dressing for fracture of the femur in children, complete. 

more accessible, are laid upon each side of the body. The four short 
thigh splints, made of binders' board and covered with cotton cloth, are 
secured in place by four or five strips of bandage tied in front and then 
stitched to the covers of the splints. These must not embrace the long 
side-splint. The broken limb below the knee, and the opposite thigh and 
leg are then secured to the long splints by separate and broader strips of 
cloth. My object in substituting, in this case, separate strips for. the 
roller, is to render the limb more accessible to the surgeon, to enable him 



FRACTURES OF THE SHAFT OF THE FEMUR. 417 

more readily to remove portions which are soiled, and to leave the leg 
more free to be drawn downward, in case permanent extension is em- 
ployed. 

Thus secured and laid upon a bed, such as I have already described as 
appropriate for children, the least possible annoyance will be given to the 
surgeon. The dressings are but little liable to become wet with urine, 
and when the bed is soiled, the child can be taken up with the splint and 
carried to another ; indeed, this may be done as often as the patient be- 
comes restless or weary, without any risk of disturbing the fracture. In 
case the surgeon desires to use extension with adhesive plaster and weights, 
the necessary apparatus may be made fast to the bedstead, and taken off 
when the child is moved ; or it may, if thought best, be made fast to the 
foot-piece of the splint. Occasionally, with children, I employ, as a 
means of extra safety, a perineal band, drawn moderately tight, and 
fastened to the top of the splint on the side corresponding to the broken 
limb. The best perineal band is a piece of soft cotton-cloth, one or two 
yards long by three inches wide, folded lengthwise to a flat band of one 
inch in breadth, and inclosing, where it passes through the perineum and 
under the nates, a few thicknesses of paper. The paper prevents its 
drawing into a round cord. Sometimes I place between the paper and 
the folded cloth, on the side which is to be laid next to the skin, one or 
two thicknesses of cotton-wadding. To absorb the moisture, it is well to 
lay a piece of sheet lint between the band and the skin. The perineal 
band may be removed daily and renewed ; and the perineum examined 
and washed. Four or five weeks is generally a sufficient length of time 
for perfect consolidation in children under five years of age. 1 

If I have been unable to give my approval to the treatment of fracture of the 
shaft of the femur in adults with plaster-of-Paris, or to any other form of immov- 
able dressing, I am still less able to give it my approval in fracture of the same 
bone in children. The following case will illustrate its dangers: A boy, four 
years old, fell thirty feet, breaking his right thigh near its middle, causing one 
of the fragments to protrude through the flesh. The surgeon in charge, having 
reduced the fracture, applied on the fifth day a plaster-of-Paris splint from the 
toes to the groin, leaving a fenestra opposite the wound in the thigh. The child 
suffered much pain that night, and on the following morning his toes were cold. 
On the second morning after the dressing there were vesications on the toes. 
On the fourth day the toes were discolored, and an offensive odor escaped from 
the dressings. The dressings were now removed, and the toes, with a part of 
the foot, were found to be gangrenous. Subsequently the gangrene extended to 
the middle of the leg. This case had been seen and the condition of the toes 
noted each day by the surgeon, but he did not become alarmed until the fourth 
day. I was consulted, and advised the continuous hot-water bath as preferable 
to amputation under the circumstances. The surgeon adopted my suggestion, 
and in about three weeks the limb separated spontaneously, the gangrene having 
never extended after the limb was submerged in the bath. His recovery has 
been complete. 2 

[While this case is most instructive, and conveys a forcible lesson as to the 
dangers of the careless use of the plaster-of-Paris dressing in children, it should 
not deter those who are competent to employ this dressing from its use. The 
unfavorable results which follow its application are always due to strangulation 
of the limb. This condition can certainly be avoided, and will only occur when 

1 Fractures of Shaft of Femur in Children. A clinical lecture by the author at Bellevue, 
Medical Record, Jan. 5, 1878. 

2 Medical Record, March 15, 1879, p. 257, case reported by Dr. Forest. 

27 



418 



FRACTURES OF THE FEMUR. 



there is culpable carelessness. To prevent strangulation of the limb it is only 
necessary — (1) to delay the dressing until the swelling due to the injury has 
abated; (2) to underlay the plaster with a proper yielding medium, as cotton- 
batting; (3) to apply the turns of the roller so lightly as merely to encase the 
limb with moderate firmness.] 

In 1877, Scliede, of Berlin, adopted a method of treating fracture of 
the thigh in children, which he calls "vertical extension." The method 
of treatment is as follows: "A long, continuous band of plaster is fixed 
to both sides of the injured limb, as high as the seat of fracture, and 
applied so as to form a free loop below the sole. This" long strip is then 
secured in the ordinary way by circular strips of plaster, and by circular 
turns of a bandage. The leg, having been elevated, is then kept in the 
vertical position, with the corresponding side of the pelvis suspended by 
means of a piece of cord fixed to the loop of plaster, and either attached 
above to some object over the bed, or slung over a pulley, with its free 
extremity supporting a weight." This does "not necessitate constant 
and complete rest on the back." At the end of about three weeks, when 
the fragments are usually consolidated, the extension is removed, and the 
limb is permitted to rest upon the bed. The only disadvantage stated is 
the occurrence, in some cases of females, of a severe vaginal catarrh, due, 
as is supposed, to the free entrance of air into the gaping ostium vagina). 

By Schede's method the patient is during the entire period of treatment con- 
fined to the bed, while in horizontal extension he is not. Inconvenience must 
also be experienced in the vertical extension in the adjustment of the coverings, 
and especially in cold weather, which inconvenience is avoided in horizontal 
extension. It must be added, also, that although in children of this age the frag- 
ments are usually firm in three or four weeks, it has not been found safe, in my 
experience, to remove wholly restraints until a week or two later. The contrary 
practice has every now and then resulted in a bending at the seat of fracture, 
which had subsequently to be remedied. My double splint, with only moderate 
confinement of the body and limbs, without extension or 
short splints, prevents this unfortunate accident in the later 
days of the treatment, while in Schede's method the limb 
must be left, after the extension is removed, wholly with- 
out support. No evidence is presented that results are any 
better than my own, by which latter method rotary dis- 
placement is impossible ; lateral displacement or bending, 
improbable ; and there is no shortening, of course, unless 
it is a complete fracture, and if it occurs then it is trivial. 

[Bryant, of London, states (Prac. Surgery) that he began 
this form of practice at Guy's Hospital in 1870, and illus- 
trates it (Fig. 262). The ages of his patients varied from 
eight months to five years ; for older patients he prefers the 
double splint. I have employed Bryant's dressing with 
good results.] 

It must be understood, however, that with any 
mode of treatment, almost, occasional good results are 
obtained ; but this is only because fractures of the 
thigh in infants are generally green-stick fractures; 
and the tendency to displacement is very slight, and 
union occurs very speedily. 

Badly comminuted and compound fractures of this bone are to be man- 
aged upon the same general principles as gunshot fractures. Those com- 



Fig. 261 




Vertical extension. 



AT OR NEAR THE BASE OF THE CONDYLES. 



419 



pound fractures of the femur which have been caused by the thrusting of 
the sharp fragments through the flesh, and in which reduction has been 
easily effected, have in most cases done as well as simple fractures, ex- 
cept that the limb is generally a little more shortened. The wound 
usually soon heals, and the future progress of the case is the same as 
that of a simple fracture. They may be treated, therefore, in the same 
manner as those which have just been described. 

§ 4. Fractures of the Shaft, at or near the Base of the Condyles. 

Causes. — These fractures are not so common as fractures of the shaft 
elsewhere ; twenty examples are contained in my records as having come 
under my personal observation. According to my own experience, they 
are caused generally by a fall upon the knees or feet. In at least nine of 
the cases seen by me the fracture was caused in this manner. In seven 
it is known that the fracture was caused by a direct blow. The direction 
of the line of fracture is generally from behind forward and downward, 



Fig. 263. 



Fig. 264. 





Fracture at the lower part of the shaft of 
the femur: action of muscles. (Hind.) 



United fracture at base of condyles. 



the upper fragment being driven downward toward the patella ; in other 
cases the line of fracture preserves the same general direction, but inclines 
inward or outward ; and in these cases the upper fragment is found lying 
more or less on the inner or outer margins of the knee, probably most 
often on the inner side. In one instance I found both femurs broken at 
the same point and in the same manner. 



420 FRACTURES OF THE FEMUR. 

L. B., aged about forty-five years, fell from a fourth-story window to the stone 
pavement blow, striking upon his feet. In addition to several other fractures, 
I found both femurs broken obliquely downward and forward, just above the 
condyles. Very little inflammation ensued, and although it was found impos- 
sible to employ extension, union occurred readily, and with only a moderate 
overlapping. In the left limb, however, the upper fragment pressed down suf- 
ficiently to interfere somewhat with the patella, arid the patient was unable, 
after several months, to straighten the knee completely. The motions of the 
right knee were unimpaired. 

I have only once met with a fracture at this point in which the line of 
separation was downward and backward. A boy, set. 7, in jumping 
down a bank of about three feet in height, broke the right thigh 
obliquely, just above the knee-joint. Direction of the fracture obliquely 
downward and backward. The limb was not then much swollen. The 
surgeon applied side-splints, rollers, etc., carefully, and then laid the 
limb over a double-inclined plane. The knee was elevated about six or 
eight inches. Before applying the splints, suitable extension had been 
made, and after completing the dressings, the two limbs seemed to be of 
the same length. On the second or third day the toes looked unnaturally 
white, and were cold. The result was that a considerable portion of his 
foot died and sloughed away, leaving only the tarsal bones. The frac- 
ture united, but with considerable overlapping and deformity. 

Nearly two years after, on examining the limb, I noticed that the anterior 
line of the femur seemed nearly straight, and this appearance was owing in some 
degree to the muscles which covered and concealed the bone, and in some degree, 
also, to the manner in which the fragments rested upon each other ; the pointed 
superior end of the lower fragment resting snugly upon the front of the upper 
fragment, so that no abrupt angle existed in front. On the back of the limb, 
however, the lower end of the upper fragment, quite sharp, projected freely 
downward and backward into the popliteal space, so that its extreme point was 
only about half an inch above the line of the articulation. The limb had short- 
ened one inch, and this enabled us to determine accurately that the lower point, 
or the commencement of the fracture, was one inch and a half above the articu- 
lation, while the point where the line of fracture terminated in front was prob- 
ably quite three inches and a half above the joint. The motions of the knee-joint 
was pretty free. The leg was extremely wasted, and the anterior half of the foot 
having sloughed off, the sores had now completely healed over. He was able to 
walk tolerably well without either crutch or cane. The case came into court, where 
it was claimed that the death of the foot was in consequence of the bandages 
being too tight. It was shown that the death of the toes was preceded by a total 
loss of color, and that it was not accompanied with either venous or arterial con- 
gestion. The medical gentlemen examined as witnesses declared that this cir- 
cumstance furnished the most positive evidence which could be desired that the 
death of the toes was not due to the tightness of the bandages, but that its cause 
must be looked for in an arrest of the arterial or nervous currents supplyiug the 
limb, or in both. They believed, also, that the projection of the superior frag- 
ment into the popliteal space was sufficient to cause this arrest. They also be- 
lieved that overlapping and consequent projection could not have been prevented 
in this case, and that, therefore, the treatment was not responsible for this un- 
fortunate result; indeed, they regarded the treatment as correct, and the result 
as a triumph of skill, in that any portion of the limb was saved ; the leg and foot 
now remaining being far more useful than any artificial leg and foot could be. 

Specimen 121, in Marsh's collection at Albany, presents a similar disposition 
of the fragments. The fracture is oblique, from above downward and backward, 
and the upper portion lies behind the lower. It is firmly united by bone, but 
with an overlapping of from two and a half to three inches. It had been found 



AT OR NEAR THE BASE OF THE CONDYLES. 421 

impossible, owing to an ulcer upon the heel, and to other causes, to employ in 
the treatment any degree of extension. 

Amesbury has recorded one case, which came under his own observation, 
where, although the bloodvessels and nerves escaped, the bone projected through 
the skin in the ham, and finally exfoliated. 1 And he thinks the point of bone 
may sometimes so penetrate the artery and injure the nerves as to render ampu- 
tation necessary in order to save the life of the patient. M. Coural also has 
related a case in which an epiphysary disjunction, occurring in a child twelve 
years old, was attended with a displacement of the upper fragment backward, 
and amputation became necessary. 2 

The popliteal artery hugs the bone so closely at this point, that a dis- 
placement of the upper fragment in a direction downward and backward 
must always greatly endanger its integrity. Indeed, it is here that the 
artery and vein are in the closest contact with each other, and with the 
bone. 

Prognosis. — The prognosis in this fracture has, according to my own 
experience, a wider range than in the case of other fractures of the shaft. 
In a proportion of cases the union has been effected with little or no short- 
ening ; a result which is not surprising when we consider that at this 
point the muscular resistance which has to be overcome is less than at 
any other point of the shaft of the femur ; and that occasionally the line 
of fracture is so little oblique that the fragments being once adjusted 
support themselves completely. 

Malgaigne says that here " oblique fractures are more rare" than those which 
are nearly transverse ; but Sir Astley Cooper had never met with a transverse 
fracture at this point, nor have I ; yet no doubt they do occur here more often 
than in other portions of the shaft. Malgaigne says that M. Denonvilliers 
thought he had found in the Dupnytren museum four or five examples of ex- 
actly transverse fractures at this point, but he had not found one higher up. 

While a considerable number of these fractures may be reasonably 
expected to reach a favorable termination, a much larger proportion than 
usual of fractures of the shaft at other points are to be considered as 
very grave accidents, and in some cases as demanding immediate ampu- 
tation. This increased gravity is due, in certain examples, to the greater 
violence required to cause the fracture ; in others, to the penetration of 
the joint by the upper fragment, and in all cases the hazard may be con- 
sidered increased by the proximity of the fracture to the joint; the thin- 
ness of the soft coverings renders them more liable to be made compound 
by the penetration of the skin by the upper fragment ; and, finally, there 
exists the danger that this fragment will penetrate the tendon of the 
quadriceps, or its tendinous expansions on either side, and become but- 
ton-holed, thus interposing a portion of this dense fibrous tissue between 
the fragments, and preventing bony union, as happened in two of the 
cases already recorded. If the direction of the fracture is from before 
upward and backward, as happens only very rarely, there is danger of 
the fragments pressing upon the popliteal artery, vein, and nerves, and 
causing a secondary hemorrhage, or gangrene of the leg, as happened 
with the boy Aiken. 

1 Remarks on Fractures, etc., by Joseph Amesbury, vol. i. p. 293. London, 183 L. 

2 Archiv. Gen. de Med., torn. ix. p. 267. 



422 FRACTURES OF THE FEMUR. 

The treatment of the accident has already been discussed in connection 
with fractures of the shaft in general ; and the conclusion would seem to 
be that, except in the last-named and exceptional fracture, as a rule, the 
straight position with moderate extension affords the most comfort to the 
patient and insures the best results. No doubt there will be cases in 
which Hodgen's swing, or some other form of the flexed position, will 
be found the most comfortable, and give equally good results ; especially 
when the parts about the knee are much swollen, or the knee-joint itself 
has been penetrated. However, in the few cases in which this position 
was adopted by myself and others, a change had to be soon made. The 
most serious question is, perhaps, What shall be the course to be pursued 
when the bone becomes buttonholed in the tendon, without penetrating 
the skin ? In neither of the two cases seen by me could the fragment 
be withdrawn from the tendon by flexion or extension, even when the 
patient was under the influence of the anaesthetic. Will it be proper, 
then, to cut through the skin, expose and remove the projecting bone, 
and then reduce it ? In one of my cases this was not done, and 
although the union was very long delayed, it is reported to have been 
finally accomplished ; but of the correctness of this report I do not feel 
assured. In the other case I resected the bone, and my patient died. 
I confess that I do not think I would be inclined to repeat the operation, 
but that I would prefer to submit my patient to the risks of non-union, 
or of a fibrous union. 

[With antiseptic precautions resection of the protruding fragment would be 
an entirely proper operation. ] 

Bryant says that he has once cut the tendo Achillis in a case of fracture at the 
base of the condyles, and he recommends it in all cases. 1 I cannot agree with 
Mr. Bryant as to its necessity or utility ordinarily, since I do not think that the 
lower fragment has that tendency to tilt backward which, in Mr. Bryant's 
opinion, renders a paralysis of the gastrocnemius necessary. This point has 
been discussed elsewhere in this chapter. Dr. Morris, of Harvard, Charlestown, 
Mass., has repeated Mr. Bryant's operation in a case in which the fracture was 
through the base and between the condyles at the same time. In this case the 
operation proved very serviceable. 2 

§ 5. Fractures of the Condyles. 

[In these injuries one condyle is separated from the other by a frac- 
ture into the joint. Direct violence, as a blow or fall upon the knee, is 
the more frequent cause. A condyle has been fractured by the mere 
twisting of the leg. The diagnosis is readily made, owing to the mobility 
of the separated fragments and the mobility of the leg toward the frac- 
tured condyle. There is no shortening, but the breadth of the knee is 
increased.] 

(a) Fractures of the External Condyle.— Crosby 3 relates a case of fracture 
of the external condyle, in a man twenty-one years of age. He was "standing 
on a shelving bank, with the right leg flexed over the left in order to remove his 
pantaloons ; he lost his balance, partially twisted the leg, and fell to the ground." 

1 Bryant, Lond. ed., 1872, p. 936. 

2 Morris, Med. Record, March, 1878, from Boston Med. and Surg. Journ., Nov. 1877. 

3 Crosby, New Hampshire Journ. of Med., 1857. 



FRACTURES OF THE CONDYLES. 



423 



Six months after the fragment was removed by Dr. Crosby, through an incision 
below the condyle. The recovery has been complete. The accompanying 
drawing represents the specimen as seen from its lower or cartilaginous sur- 
face, and of its actual size. (Fig. 265.) 

J. O'N,, set. 40, fell down stairs, bending his left leg under his body, and frac- 
turing the external condyle. About three months later the patient was brought 
under my notice. He was able to walk with a slight halt; the fragment, 
apparently about one inch in diameter, moving upward about half an inch 
when the leg was flexed, with a distinct and painful crepitus. When at rest, the 
fragment formed a marked projection. It is not certain whether the line of 
fracture entered the joint. I examined the limb several times during the suc- 
ceeding two years, and found the condition of matters unchanged, except that 
the usefulness of the limb has steadily improved. Bandages and knee-supports 
have served no useful purpose, and have been laid aside. 

Dr. T. S. Kirkbride has also reported an example of simple fracture of this 
condyle, which was produced by the kick of a horse, the blow having been 
received upon the inside of the knee. When this patient entered the Pennsyl- 
vania Hospital, Dec. 1834, the knee was much swollen, and crepitus was plainly 



Fig. 265. 



Fig. 266. 





Dr. Crosby's specimen of fracture of 
the external condyle. 



Sir Astley Cooper's case of fracture of 
the external condyle. 



felt, but the fragment was not displaced ; the muscles upon the outer side, how- 
ever, were so strongly contracted as to abduct the leg, and produce considerable 
angular deformity. The limb could be easily made straight, but it returned to 
its former .position of abduction as soon as it was released. When fully extended, 
slight bending of the joint did not give severe pain ; but when in any degree 
flexed, all motion was very painful. The limb was placed in a long straight 
fracture-box, and cold applications were made ; great swelling followed. It was 
kept extended in this manner, or in the long splint of Desault, twenty-eight 
days ; at which time union seemed to have taken place, but the motions at the 
joint were very limited, and productive of great pain. From this period the 
limb was laid in a splint, so constructed that the angle of the knee could be 
changed daily. At the end of about six weeks he began to walk on crutches, 
and he could then flex the leg to a right angle. 1 

Sir Astley Cooper has related a case of compound fracture of the same con- 
dyle, produced by falling from a curbstone upon the knees. The man died on 
the twenty-fourth day. On examination after death, the external condyle was 



1 Kirkbride, Amer, Journ. Med. Sci., May, 1835, vol. xvi. p. 32. 



424 



FRACTURES OF THE FEMUR. 



found to be broken off, and also a considerable fragment was detached from the 
shaft higher up. 1 (Fig. 266.) 

(b) Fractures of the Internal Condyle. — Dr. Rggs, of Homer, N. Y., 
reports the following case : 

A lad, set. 15, was kicked by a horse, the blow being received upon the right 
knee. The internal condyle of the right femur was broken off, carrying away 
more than half the articulating surface of the joint; the tibia and fibula were at 
the same time dislocated inward and upward, carrying with them the broken 
condyle and the patella. The displacement upward was about two inches, and 
the sharp point of the inner fragment had nearly penetrated the skin. There 
was no external wound. The knee presented a very extraordinary appearance, 
and the lad was suffering greatly. The first attempt at reduction was unsuccess- 
ful ; but in the second attempt, when the men aiding him were nearly exhausted 
in their efforts at extension and counter-extension, and while pressing forcibly 
with both hands upon the two condyles, the bones suddenly came into position, 
except that the breadth of the knee seemed to be slightly greater than the other, 
a circumstance which was probably due to the irregularities of the broken sur- 
faces, which prevented perfect coaptation. Neither splints nor bandages were 
required to maintain the bones in place ; the limb was placed upon " a double 
inclined plane," which, being supplied with lateral supports, would prevent any 
deflection in either direction, in case the limb was disposed to such displacement. 
The subsequent treatment consisted in the use of cold-water dressings. Very 
little inflammation followed. A portion of the integument sloughed, but the 
bone was not exposed, and it healed rapidly. On the twenty-fourth day passive 
motion was used, and this was repeated at intervals until, at the end of three 
months, he was able to walk with a cane. At the end 
of a year, the knee was a very little larger than the 
other, and flexion was not quite as complete. In all 
other respects it was perfect, and the boy himself de- 
clared it was as good as the other. 

The Dupuytren museum contains a specimen illus- 
trating this fracture, which was presented to the museum 
by Yerneuil, and is referred to by Trelat. 2 The frag- 
ment was not displaced. 

f Treatment of Fractures of either Condyle.- 

1 The few cases of these accidents which I have 

I seen reported have been, with one or two excep- 

tions, treated in the straight position. In Kirk- 
bride's case any degree of flexion was painful, 
although there was little or no displacement of the 
fragment ; and we think we can see, in the relative 
position of the articular surfaces of the tibia and 
femur, a sufficient reason why the straight or nearly 
straight position must generally be preferred. 
Whichever condyle is broken, the remaining con- 
dyle will be sufficient to prevent a dislocation and 
consequent shortening of the limb, unless, indeed, 
the dislocation has already occurred as an immediate consequence of the 
injury. It is very certain that it would not take place from the action 
of the muscles when the limb was straight. In the flexed position I can 
conceive that it might take place, but yet not easily. It is not a dislo- 



Fig. 267. 




Fracture of the inter- 
nal condyle. ( Verneuil's 
case.) 



1 Sir Astley Cooper, on Disloc, op. cit., p. 239. 

2 Verneuil, Trelat, Arch. Gen. de Med., 1854, t. ii. p. 78. 



FRACTURES OF THE CONDYLES. 425 

cation of the limb, then, that we seek chiefly to avoid, but a deflection 
of the leg to the right or to the left, according as one or the other of 
the condyles has been broken. It will be readily seen that, in order to 
resist this tendency, nothing but the straight position will answer, and 
that for this purpose it will be necessary to lay a long splint upon one 
or both sides of the limb, and to secure the whole length of both thigh 
and leg to this splint. The long fracture-box used by Kirkbride, if well 
cushioned on all sides, seems to me at once to answer most completely 
this important indication, rendering it even unnecessary to employ a 
bandage, since the opposite sides of the box will compel the limb to 
adopt the proper position. As to the remainder of the treatment, it 
must consist essentially in the employment of such means as are calcu- 
lated to prevent and allay inflammation. 

[When the acute swelling has begun to subside the plaster-of-Paris dressing 
is most useful. The knee should be protected by a layer of cotton-batting, and 
the plaster should extend from the middle of the leg to the middle of the thigh. 
While the dressing is being applied the limb should be held in proper position, 
and the condyle fixed in firm contact with its fellow by pressure.] 

As soon as the union is consummated the joint-surfaces should be sub- 
mitted cautiously to passive motion, in order to prevent ankylosis ; and 
it would be better to commence this so early as to hazard somewhat a 
displacement of the fragment, rather than to wait too long. It may not, 
in some cases, be improper as early as the fourteenth day, and in nearly 
all cases it should be practised as early as the twenty-eighth. Of course, 
the presence of active inflammation in the joint would render motion 
improper. 

(c) Fractures between the Condyles and across the Base. — A frac- 
ture of- this character may be produced by a blow received directly upon 
any point of the lower extremity of the femur ; sometimes the blow has 
been received upon the patella when the knee was bent, and Bichat men- 
tions a case in which it was produced by a fall upon the feet. 

Symptoms. — This fracture is easily distinguished from the preceding 
by the much greater mobility of the fragments and by the palpable 
shortening of the limb, since an overlapping of the broken end is here 
almost inevitable. Each fragment may be felt to move separately, and 
the motion will be accompanied with crepitus. 

Prognosis. — The danger of violent inflammation in the joint is im- 
minent, and ankylosis of the knee is to be anticipated as the most favor- 
able result, since the joint-surfaces are likely to be rendered immovable 
by fibrinous deposits in their immediate vicinity, and also by the adhe- 
sion of the muscles to one another and to the bone higher up; at the point 
where the fracture of the shaft has occurred. More fortunate results 
than these may, indeed, be hoped for, inasmuch as they have occasionally 
been noticed, but they cannot fairly be expected. 

In a majority of cases such accidents have demanded, either immediately or 
at a later period, amputation. If recovery takes place, a shortening of the thigh 
is inevitable. Mr. Canton, of London, has twice performed successfully resec- 
tion of the joint-end of the bone in such accidents. 1 

1 Canton, Lancet, Aug. 28, 1858. Trans. London Path. Soc, 1850. 



426 FRACTURES OF THE FEMUR. 

Treatment. — Malgaigne saw a patient who had been treated by Guer- 
bois, with the aid of extension and counter-extension, who was confined 
to his bed five months, and who had at the end of eight years very little 
motion in the joint, and he seems disposed to charge in some measure 
these unfortunate consequences to the position in which the limb was 
placed, namely, the straight position. But, in my opinion, it is much 
more reasonable to suppose that, if the treatment was at all responsible 
for the results, the error consisted in too long and unnecessary confine- 
ment and in too much extension. I suspect that the mere matter of 
position had nothing to do with the ankylosis. Malgaigne does not, 
however, himself recommend anything more than a very slight amount 
of flexion at the knee; and to this practice I am prepared to give my 
assent ; since it will give to the limb a useful position in case ankylosis 
does occur, and it is not inconsistent with the employment of the mod- 
erate amount of extension which alone is justifiable after this accident. 
If the young surgeon should differ with me in opinion as to the necessity 
or propriety of using great force to retain the fragments in place and 
prevent overlapping, I beg him to consider that this fracture probably 
never happens except from the application of an extraordinary force, 
and that consequently intense inflammation and swelling are almost 
certain to ensue : and that in some cases, the very fact that immediately 
after the accident, or for some hours succeeding, no swelling occurs, or 
muscular contraction, and that replacement of the fragments is easily 
accomplished, is evidence only of the great severity of the injury, and 
that the whole system is prostrated by the shock ; to which, if the patient 
does not succumb, sooner or later reaction will ensue and the fragments 
will be gradually drawn up with a resistless power. The surgeon ought 
to remember also that to make extension in this case, he is obliged to 
pull upon those very ligaments and tendons about the joint which, having 
been torn or bruised, must soon become exquisitely sensitive. 

The long straight box, already recommended when speaking of frac- 
ture of one condyle, is equally applicable here ; only that it needs a foot- 
board, or some sort of foot-piece to which an extending apparatus may 
be secured, and that a pillow should be placed under the knee to give the 
limb the proper flexion. . . 

A man was admitted into St. Thomas's Hospital, London, Sept. 17, 1816, with 
a fracture between the condyles, accompanied also with a fracture through the 
shaft higher up, occasioned by being caught in the wheels of a carriage while in 
motion. There was a small wound opposite the point of fracture, and the 
external condyle was displaced outward. The limb was laid in a fracture-box, 
and in a position of semiflexion. On the 18th of November, the external con- 
dyle, having protruded through the skin, and being dead, was removed with the 
forceps, bringing with it a portion of the articular surface. On the 6th of 
December he was discharged from the hospital, and in February following he 
was walking without any support, and with the free use of the joint. 1 

A gentleman living about eighty miles from town was thrown from his car- 
riage, breaking the left femur just above the condyles into many fragments, so 
that when I saw him on the following day the attending physician showed me 
about four or five inches of the entire thickness of the shaft which he had re- 
moved. The external condyle was completely separated from the internal, and 

1 Sir A. Cooper on Disloc, etc., op. cit., p. 239. 



FKACTURES OF THE CONDYLES. 427 

was quite movable. In this case the attempt to save the limb resulted in the 
loss of the patient's life on the sixth or seventh day. In a case of this kind, Dr. 
Morris, of Charlestown, cut the tendo Achillis with an excellent result. 1 

(d) Separation of the Lower Epiphysis. — M. Coural 2 relates the case of a 
boy eleven years old, who, while his leg was buried in a hole up to his knee, fell 
forward, separating the lower epiphysis from the shaft, and at the same time 
driving the shaft behind the condyles into the popliteal space. The epiphysis 
also became tilted in such a manner that its lower extremity was directed for- 
ward. The limb was amputated. 

Madame Lachapelle mentions a case in which traction at the foot of a child 
in the act of birth, caused at the same time a separation of the lower epiphysis 
of the femur and the upper epiphysis of the tibia. The child was born dead. 3 

Dr. Halderman, 4 of Columbus, Ohio, Professor of Surgery in the Starling 
Medical College, reports a case in a boy, 18 years old, caused by a violent blow 
upon the front and lower part of the thigh. The limb was shortened two inches. 
It was found impossible to reduce the fracture, even under the influence of ether. 
Gangrene ensued, and on the fifth day the limb was amputated. On examina- 
tion it was ascertained that the epiphysis was separated completely, and carried 
backward by, the action of the popliteus and gastrocnemius; the popliteal artery 
and vein, and the internal popliteal nerve were displaced forward, lying between 
the upper and lower fragments, and were much contused. The epiphysis was 
lodged above the internal condyle in such a way that it would have been impos- 
sible to displace it by traction. 

Dr. Little presented to the New York Pathological Society a specimen obtained 
from his own practice. A boy, set. 11, while hanging on the back of a wagon, 
had his right leg caught between the spokes of the wheel which was in rapid 
motion. A few hours after the accident, Dr. Little found the upper fragment 
of the femur projecting through an opening in the upper and outer part of the 
popliteal space. On examination, the wound did not appear to communicate 
with the knee-joint. Under the influence of an anaesthetic the fragments were 
reduced ; the reduction occasioning a dull cartilaginous crepitus. There was at 
the time no pulsation in the posterior tibial artery, and the limb was cold. The 
limb was laid over a double-inclined plane. The following day the upper frag- 
ment was again displaced, and it was found that it could only be kept in place 
by extreme flexion of the leg. This position was therefore adopted and main- 
tained ; considerable traumatic fever followed, with swelling, and on the thir- 
teenth day a secondary hemorrhage occurred from the anterior tibial artery near 
its origin, and it became necessary to amputate. The boy made a good recovery. 
The specimen showed that the line of separation had not followed the cartilage 
throughout, but had at one point traversed the bony structure. 

Dr. Voss, at the same meeting, remarked that he had met with the same acci- 
dent. There was no protrusion of bone, but an abscess formed, and it became 
necessary to amputate. 

Dr. Buck saw a case which occurred in the practice of Dr. Hugh Walsh, of 
Fordham. The subject was a boy 14 years old, and it happened in the same 
manner as with Dr. Little's patient. 5 

Tapret and Chenet 6 have reported a similar example caused in the same 
manner, in a boy 9 years old. The integuments were lacerated and there was 
considerable hemorrhage. The limb was dressed with plaster-of-Paris, but after 
a few days gangrene ensued in the region of the parts wounded, and it became 
necessary to amputate. On examination, it was found that the fracture, com- 
mencing externally, followed the line of union between the epiphyseal cartilage 
and the shaft, but toward the inner side it deviated a little, so as to include a 
small portion of the diaphysis. 

The same accident has been frequently caused by attempts to straighten the 

1 Morris, Boston Med. and Surg. Journ., Nov. 1877. 

2 Coural, Arch. Gen. de Med., vol. ix. 1825, p. 337. 

3 Mad. Lachapelle, Prat, des Accouch., t. 2, p. 225, and t. 3, p. 180. 

4 Halderman, Med. Eecord, July 3 1882, p. 600. 

5 Little, Voss, Buck, New York Journ. Med., Nov. 1865. 

6 Tapret and Chenet, Bull. Soe. Anat. de Paris, 1875, p. 25. 



428 FRACTURES OF THE FEMUR. 

limb in cases of ankylosis in children. Chauvel 1 saw a case in which, the sepa- 
ration having been produced in this manner, suppuration ensued, and the patient 
died of pyaemia. Volkmann' 2 says that he has three times detached the epiphysis 
by rotating the thigh while seeking for crepitus in patients suffering from hip- 
joint disease, or by traction made while applying a plaster-of-Paris dressing. 

Wm. Smallwood, set. 12, August 11, 1877, had his right leg caught in the 
spokes of a wagon-wheel, breaking the thigh at the junction of the lower epiph- 
ysis with the diaphysis, the lower end of the upper fragment protruding five 
inches through the flesh. The end was nearly square. His father, Dr. S. B. 
Smallwood, of Astoria, N. Y., the lad being under the influence of ether, reduced 
it within one hour by violent extension and flexion of the leg over his knee, one 
finger being in the wound, and adjusting the fragments. Lateral splints were 
employed. The wound closed in about nine months, and in the meanwhile two 
small fragments of bone escaped. He had also a sharp attack of synovitis. I 
examined him April 18, 1880, and found the leg straight, but shortened three- 
quarters of an inch. There is complete ankylosis of the knee-joint, but the 
muscles of the leg are well developed, and he walks with very little limp. 

§ 6. Non-union and Delayed Union of Fractures of the Shaft of the 

Femur. 

Examples of delayed and of non-union of the shaft of the femur are 
not very infrequent, yet I must be permitted to say that complete failure 
to unite by bone has never occurred in my practice when I have had 
charge of the patient throughout ; and I cannot but think that in some 
of the cases which have come under my notice the mode of treatment 
was responsible for this unfortunate result. The fragments have not 
been properly supported, or there has been allowed too much freedom of 
motion. In other cases, no doubt, the cause of delay was some of those 
conditions of the patient or of the fracture which have been explained in 
the general chapter on delayed and non-union. 

A strong conviction has forced itself upon me that it is never proper, 
in the ease of this bone, to resort to either resection and the wiring of 
the. bones together, or to a seton, or to other means of establishing any 
considerable continuous or permanent irritation, with the view of excit- 
ing the tissues to the deposit of bony callus. The femur lies too deeply 
imbedded in a mass of muscular and tendinous tissue to make it safe or 
prudent to excite suppurative action in the neighborhood of the bone, 
even if the drainage were the most perfact ; and both of these methods, 
thoroughly carried out, insure suppuration. To this danger these 
methods have to add the necessity, during a long period of time, of 
confining the patient in splints and in bed; while in the case of all the 
other long bones — even in the case of the leg, but especially of the upper 
extremities — it is possible to permit the patient to go about, and thus to 
retain his general health — a condition most essential to the process of 
repair. 

[The opinion that it is unsafe to perform any operation for ununited fracture 
of the femur which would excite suppuration is correct. I passed a seton be- 
tween the fragments twenty-five years ago and lost my patient by pyemia. But 
resection and wiring these bones do not, to-day, excite suppurative action, and 
hence are proper operations when antiseptically performed. The statistics of 

1 Chauvel, Diet. Encyc., Art. Cuisse, p. 233. 

2 Volkmann, Virchow's Jahresb., 1866, 2, p. 337. 



FRACTUKES OF THE PATELLA. 429 

mortality from resections performed in the pre-antiseptic period are valueless 
except for historical comparisons.] 

The strictly surgical expedients which are most likely to prove suc- 
cessful in cases of simply delayed union, and which sometimes have 
proved successful in cases of non-union, after the lapse of months or 
years, are violent twisting of the limb and drilling ; the drilling being 
made thoroughly through the ends of the fragments, at several points, 
and repeated from time to time, while the limb is at rest and inclosed 
in splints. 

In Muhlenberg's table of cases published by Agnew, there are 17 cases treated 
by "manual friction," of which 7 were cured, 10 failed, and none died. Of 18 
cases treated by " drilling with its modification," 9 were cured, 8 failed, and 
1 died. 

In the following case I succeeded by manual frictions, drilling, perforation, 
and mechanical apparatus combined, or successively employed: May 1, 1877, I 
perforated the fragments in various directions with Brainard's instrument, then 
bent the limb violently and applied splints. On the 7th I opened and tightened 
the dressings. The following day I pushed an ordinary shawl-pin down to and 
between the fragments, leaving it in place twenty-four hours. On the 10th of 
May I again introduced a shawl-pin and left it in seven days, causing a slight 
suppuration near the skin. This was repeated on the 23d, and it was allowed to 
remain again seven days. I think this was repeated once or twice more. July 
12th, bored through both fragments with a gimlet, and left it in forty-eight 
hours. Aug. 7th, I again used the perforator very thoroughly, and left it in 
forty-eight hours. Then had constructed for him an artificial support for his 
thigh and leg. On the 17th of August the fibrous union was very close and firm. 
November 1, 1878, the fragments were firmly united by bone — a period of six 
months since the treatment was commenced. He walks long distances without 
a cane or other means of support, and the consolidation is complete. 

In another similar case I was not equally successful. I have twice seen the 
same measures fail in the hands of other surgeons. As to the value of mechanical 
supports; which permit the patient to go about with or without crutches, there 
can be no doubt ; yet the reported successes of this method are not very numer- 
ous, at least in the case of old ununited fractures of the femur. 

Muhlenberg, in his tables, reports 29 cases treated by mechanical appliances 
alone, of which 22 were cured, 2 were relieved, 4 failed, and 1 died. Probably 
some of these were recent cases. 



CHAP TEE XXX. 



FRACTURES OF THE PATELLA. 



In 1880, I made a careful study of 127 cases of fracture of the 
patella. Of these, 71 were either treated by me, or they were seen by 
me in consultation in the course of the treatment, or came subsequently 
under my notice. Of nearly all of these I made careful notes at the 
time. The remainder of the 127 cases (56) are copied from the Bellevue 
Hospital records, including all that had been recorded up to the date of 
the completion of the study ; excluding only those which had been 



430 FRACTURES OF THE PATELLA. 

treated by myself, and were included, therefore, in the class of cases first 
mentioned. The following is a summary of those cases r 1 

fe.— Males, 99 ; females, 28. 

Age. — Ten years and under, one case. This is the case (52) of a lad five years 
old, in whom from a direct blow, a small piece of the margin of the patella was 
broken off. 

From ten years, including twenty, six cases; of which 1 (113) was 16 years 
old — a boy — the fracture being oblique and caused by a direct blow ; 1 (case 19) 
was 19 years old — the fracture was transverse, and was caused apparently by a 
direct blow. In this case the ligament subsequently gave way completely on 
the outside, and a new patella formed in the very much elongated ligament on 
the inner side. The remaining four cases were at the age of 20 years ; all were 
transverse ; two are known to have been caused by muscular action — one by 
direct force, and in one the cause is not stated. 

Before the twentieth year of life, then, there were only three fractures, and 
these were all supposed to be caused by direct blows. Up to this period, mus- 
cular action seems to take little or no part in the production of these fractures. 

From twenty years, including thirty, 48 cases. From thirty years, including 
forty, 33 cases. From forty years, including fifty, 22 cases. From fifty years, 
including sixty, 8 cases. From sixty years, including seventy, 4 cases. From 
seventy years, including eighty, 1 case. In this one case, the patient, a woman, 
was eighty years old. 

In all the six cases included in the last two decades — that is, from sixty years, 
including eighty, four are known to have been caused by direct blows, and the 
remaining case, 80 years old, fell fifteen feet, and it is fair to presume that the 
fracture was caused by a direct blow. 

It would seem, then, that after the sixtieth year, muscular action alone seldom 
causes these fractures, the largest number of cases having occurred between the 
twentieth and fortieth years of life ; the total in these periods being 103, out of 
122 whose ages are known, or, if we include the three at the twentieth year, 106 
out of 122 cases. 

Of 134 in which this fact is recorded, ninety-three were in the left limb, and 
forty-one in the right. 

Of the whole number, all were simple, except eleven ; and of these, nine were 
comminuted, and two were both compound and comminuted. Of the commi- 
nuted fractures, cases 61 and 94 were accompanied with fractures of the thigh 
also — one died of shock on the fourth day, and one died after amputation, ren- 
dered necessary by gangrene. 

The fractures were transverse in 106 cases — not including two which were 
transverse and vertical (comminuted) — of these 106 cases, twenty-two are re- 
corded as below the middle of the patella, sixteen at the middle, and seven above 
the middle. Twenty-five are known to have been the result of muscular force 
alone ; and fifty-eight are recorded as having received blows upon, or as haying 
fallen upon the patella, and have been placed in the list of those caused by direct 
blows. In forty-three cases nothing is said as to the cause. 

Of the transverse fractures, a majority of those occurring below the middle are 
ascribed to muscular action — that is, twelve out of twenty in which the cause 
is given. Of four oblique fractures, three are known to have been from direct 
force ; and all of the comminuted fractures, except case 127, were from direct 
blows, as were also the two compound fractures. 

I infer that active synovitis ensued in at least thirty-four cases, and probably 
in many others. Inflammation of the bursa of the patella is mentioned once. 
Probably in most cases the bursa is torn open as the patella ascends, and com- 
municates freely with the joint, so that bursitis could not be recognized as a dis- 
tinct phenomenon. 

In case 90, a compound fracture, the presence of blood in the joint was actually 
demonstrated. Probably it was present in many other cases, but the fact could 

1 Fracture of the Patella. A Study of 127 Cases, by Frank H. Hamilton, M.D. New- 
York : Charles L. Bermingham & Co., 1880. 






FRACTURES OF THE PATELLA. 431 

not be proven. Pretty extensive subcutaneous ecchymoses on the sides of the 
knee and in the ham were very frequently observed. 

Nearly all of the recognized plans of treatment were adopted, but in a majority 
of cases the same plan of treatment was not continued from the beginning to the 
close ; and it would be difficult in most cases to say to which particular method 
the result must be ascribed. Of the specific forms of apparatus, there are men- 
tioned Lausdale's, Wyeth's, Turner's, Mott's, Malgaigne's hooks, Sir Astley 
Cooper's, both of my own methods, plaster-of-Paris, and other forms of immova- 
ble dressings, the "lock strap," "wooden fingers,'' pulley and weight, crescentic 
pads, and figure-of-8 bandages, also elastic bands, rollers, etc. Most of the 
patients have been kept in the recumbent posture, with the foot elevated ; but 
some have been allowed to walk about on crutches, especially when either of the 
forms of immovable apparatus has been employed. 

It is stated distinctly in 84 cases that the union was fibrous. The bond of 
union did not permit the fragments to be moved upon each other soon after the 
treatment was concluded, and therefore may have been constituted of bone, in 
three or four other cases. In three cases no union ever occurred. 

The length of the bond of union is given as \ of an inch in 16 cases ; \ in 33 
cases; | in 13 cases; 1 inch in 3 cases; \\ in 2 cases; 2 in 3 cases; 3 \ in 1 case; 
4 in 1 case, and 5 in 1 case. The last four cases, or those in which the separa- 
tion exceeds \\ inches, are respectively cases 22, 23, 54, and 111. The above 
records, ii. will be understood, do not include cases of rupture subsequent to 
union, but only the results of the first treatment. It is not to be supposed that 
these estimates of the length of the bond of union are absolutely accurate. 
Probably the length of the ligament was generally a little more than is stated, 
but the records are sufficiently accurate for our purposes. All but 8 are united 
with a ligament of one inch or less in length, and the largest number have a 
ligament of only half an inch. 

Ankylosis — more or less complete — has existed in nearly all of the cases when 
the limb was first removed from the apparatus ; being most complete, as a rule, 
in those cases in which the joint has been kept the longest in the dressings, with- 
out the use of passive motion. In no case recorded has force been resorted to to 
overcome this ankylosis ; but it has gradually disappeared under passive and 
active use of the limb within a year or two. 

The new ligament has given way more or less completely in 27 cases. Possi- 
bly we may have included in this number one or two which were never held well 
in position, in which the inner portion of the ligament alone is elongated. This 
unilateral elongation occurred three times on the inner side and once on the 
outer. Of the entire number, 5 were gradual, the elongation commencing soon 
after the patients began to walk ; and 18 occurred within ten weeks after the 
receipt of the original injury, generally on the seventh or eighth week, when the 
patient in his first attempt to walk has slipped, and the limb has been suddenly 
bent. After the eighth week there are, 4 cases at 3 months, 3 at 5 months, and 1 
at 2 years and 4 months (case 18). Case 21 is put down as refractured after 4 
years ; but the history of the case is doubtful. I think, in the light of this ex- 
perience, it may be said that after the fifth month there is usually no more danger 
to the injured limb than to the sound one. 

The lower fragment was found slightly tilted forward in one case ; and the 
lower fragment overlapped the upper a little in another. The upper fragment 
was tilted over by the elongation of the inner portion of the ligament in three 
cases ; and in the opposite direction by the giving way of the outer portion in one 
case. In one case a new patella was formed in the much-elongated ligament. 

Five cases belong to this class. These latter accidents have evidently resulted 
from the fact that the sound limb has been compelled to receive alone the resist- 
ance in efforts to prevent a fall. 

Hypertrophy has been noticed in 9 cases ; namely, twice in the upper frag- 
ment alone, once in the lower, and six times in both. It is probable that its 
occurrence is much more frequent than this record implies. 

Of the primary accidents, that is, of those in which there was no subsequent 
rupture of the union, I have been permitted to examine 23 cases, at periods of 
time ranging from four months to twenty-nine years. Only four of these are 
said to have acquired perfect, or nearly perfect, use of the limb in a less period 



432 FRACTURES OF THE PATELLA. 

than two years, although in general they have resumed work within about one 
year. The cause of this inability to labor has almost invariably been the lack 
of the necessary freedom of motion of the knee-joint — a partial ankylosis. 

It is remarkable, however, that in one case, a British soldier, there being no 
union and a separation of the fragments to the extent of five inches, he was able 
to walk well at the end of twenty-nine years, when I saw him. One case was 
seen after four years with a separation of four inches, and another was seen after 
seven years, and both walked badly. 

Of i5 cases in which the ligament gave way within a period of three months 
from the time of the original accident, that is, soon after the union had been 
effected, 12 have terminated very satisfactorily. Under a renewal of the treat- 
ment the fragments have united with a short ligament. 

Having given this brief analysis of these cases, I shall proceed to 
consider the subject of fractures of the patella in a more general way. 

§ 1. Etiology of Fractures of the Patella. 

Twenty-five of the cases reported by me are known to have been the 
result of muscular force alone ; the fractures having occurred without a 
fall or while the patient was standing, and in some cases when the knee 
was not bent, the fracture being announced by a distinctly felt snap. I 
believe, however, that muscular action was more or less efficient in caus- 

Fig. 268. 





Simple transverse fracture. Comminuted fracture. 

ing the fracture, in all the simple transverse fractures, and in at least 
one of the comminuted fractures. My reasons for this opinion are : the 
great power of those four strong muscles which unite to form the tendon 
of the quadriceps — the fact that ninety-nine occurred in males — that only 
three occurred in persons under twenty years of age, and only five after 
the sixtieth year — the largest number being between the twentieth and 
thirtieth years of life — the remarkable uniformity in the direction of the 
fracture ; and finally, because I am unable to cause a transverse fracture 
on the cadaver by a direct blow. I might have added also the fact, as 
attested by museum specimens, that the fracture is very uniformly from 
before backward and downward, as would be the case if it were caused 
by a cross-strain, the active force being attached to the upper fragment. 
That the bone breaks most often in the lower third is probably due to 
the fact that when the knee is slightly bent — and this is the position of 
the limb in which the fracture generally occurs — the centre of the patella 
rests upon the condyle of the femur, leaving the upper and lower portions 
unsupported, when the lower portion, being the weaker of the two, gives 
way under the cross-strain. A patella having given away, transversely, 
to muscular action, those fibres of the quadriceps which are inserted into 
the sides of the patella still continuing to act, may break the bone verti- 
cally, or cause them to separate laterally. 



ANATOMY, PATHOLOGY, AND SEMEIOLOGY. 433 

The source of error in estimating the value of muscular action in the 
production of this fracture has been, that in the majority of cases the 
patients have actually fallen upon their knees, and all such cases have 
been set down as caused by direct force ; but in a fall on the knee upon 
a plane surface, when the leg is flexed to a right angle with the body, 
the patella does not touch the plane; it is only the tubercle of the tibia 
which touches, and the contact with the plane has had nothing to do with 
the fracture, except as causing, by the concussion, a more active con- 
traction of the muscles already rendered tense by the position and by 
the effort to prevent the fall. If a man falls headlong, with his knee 
slightly bent, the patella may strike the floor, and in this way, and by 
other methods, the patella may receive a direct blow ; but even then, if the 
fracture is transverse, it is probable that the blow induced the fracture by 
causing a sudden spasmodic action of the muscles, for, as I have said before, 
we cannot imitate the fracture by a direct blow on the patella of the cadaver. 

[When a person falls directly upon the patella there is a liability to a stellate 
fracture.] 

§ 2. Anatomy, Pathology, and Semeiology. 

I have already stated that the fracture is almost uniformly transverse, 
occasionally oblique, and in a few cases the line of fracture is slightly 
curved ; very seldom is the line of fracture vertical. The fracture occurs 
most often in the lower third, and least often in the upper third. In the 



Fig. 270. 



Fig. 271. 




Stellate fracture. (Erichsen.) 

transverse fractures the direction of 
the fractures is from before backward 
and downward. 

In a large majority of cases the 
lesion is limited to the bone, its perios- 
teal coverings, and the thin and scat- 
tered fibres of the tendon of the quad- 
riceps which traverse the front of the 
bone to become continuous with the 

28 




Transverse fracture of the patella. 



434 



FRACTURES OF THE PATELLA. 



ligamentum patellae. Perhaps a few of the fibres of the aponeurosis on 
either side of the patella give way also, but the lesion of this aponeurosis 
is ordinarily not extensive. For this reason the upper fragment seldom 
separates from the lower more than one inch, and in most cases only 
about half an inch. It is only when great and extraordinary muscular 
force has caused the fracture, that the aponeurosis is sufficiently torn to 
permit the upper fragment to ascend two inches or more ; and we may 
always estimate the extent of this latter lesion by the extent to which the 
upper fragment is drawn up. 

In a dissection which Dr. Girdner kindly prepared for me, he exposed the 
patella and the quadriceps with its broad lateral aponeurosis, which passes 
down, spreading out, to be inserted finally into the sides of the tibia and fibula 
at their upper extremities. He then divided the patella transversely with a 
chisel, leaving the aponeurosis untouched, and we observed now that by no 
amount of pressure upward short of that which would cause a laceration of the 
aponeurosis could the upper fragment be made to ascend more than half or 
three-quarters of an inch. By cutting the aponeurosis on either side, the frag- 
ment could be pushed up further, but the cutting had to be very extensive 
before it could be pushed up three inches, as has happened in some of the recent 
cases which have come under my observation. Such extensive separation, there- 
fore, implies necessarily extensive laceration of the aponeurosis. 

[Much light was thrown upon the question of the liability to ligamentous union 
in fractures of the patella, by Macewen, 1 who proved by dissections that one of 
the most constant conditions of the recent fracture is the interposition between 
the fragments of the lacerated prepatellar aponeurotic structures. This fact has 
been repeatedly established by those who operate upon recent fractures. In the 
majority of cases it is apparent that bony union could not take place except after 
the operation of wiring.] 

There is another anatomical lesion, the existence of which it may be 
proper to assume in the majority of cases, although we have not the 



Fig. 272. 



Fig. 273. 





Separation of the fragments in moderate 
flexion when the whole aponeurosis and 
tendon is torn. 



Fragments separated by forced flexion 
of the knee. 



means of demonstrating its occurrence. The posterior w T all of the bursa 
in front of the knee is probably lacerated, and the joint surfaces, or 



1 Annals of Surgery, March, 1887. 



ANATOMY, PATHOLOGY, AND SEMEIOLOGY. 435 

articular synovial capsule is made to communicate freely with the cavity 
of the bursa. 

This bursa is usually present in adult life, and is especially well developed in 
males. It posterior wall is composed of a thin synovial membrane, which is in 
direct contact with the front of the patella and its immediate investments; so 
that a separation of the fragments to the extent of half an inch could scarcely 
occur without laying open the bursa. The exception must be found in those 
cases in which the bursa is not at all, or is only imperfectly developed, or the 
fracture has taken place at a point which does not exactly correspond to the 
under surface of the bursa. I have once or twice observed, a few days after the 
fracture, a fulness in front of the patella so defined as to seem to indicate that 
the bursa had not been torn, but that it had inflamed and become filled with 
serum ; but I imagine that this appearance might be presented sometimes when 
a communication with the joint had been established, and the bursa had become 
filled, its anterior wall being simply pressed forward by the fluids of the joint. 

There remain then, usually, in front of the joint nothing but the skin 
and a thin layer of areolar tissue, or probably the skin alone, which if 
it were not at this point very redundant and elastic would often be torn, 
rendering the fracture compound. 

In no case under my notice has the skin been torn as an original accident, 
however much the fragments may have separated ; but in one case, not recorded 
in the preceding report, but which w r as at the time under the care of Dr. Erskine 
Mason, the skin was torn in a subsequent accident — a rupture of the new liga- 
ment — the fragments being separated very widely. Suppuration of the joint 
ensued, and it became necessary to amputate at the knee-joint by Cardan's 
method, after which he made a good recovery. 

It has been found possible sometimes for the patient, immediately after 
the accident, to continue standing, or even to walk by exercising great 
care, but in most cases the patients have at once fallen to the ground and 
been unable to rise. Very speedily, often within a few minutes after the 
injury is received, the joint appears swollen. This early swelling must 
be in part attributed to the effusion of blood into the joint from the 
broken patella and adjacent tissue. The presence of blood in the joint 
was demonstrated in one case, and there can be no reason to doubt that 
it is often, perhaps always, present in the joint in some amount, after the 
fracture, where it probably undergoes a pretty rapid disintegration and 
is mostly absorbed. There is quite often, also, at an early date, con- 
siderable discoloration of the skin on the sides and back of the knee, 
caused by the infiltration of the blood into the subcutaneous areolar 
tissues. A synovitis and bursitis (when the bursa is torn) are inevitable 
also ; the amount of inflammation being more or less in different cases, 
but being, in most cases, sufficient to fill the joint with serum and prob- 
ably some lymph, within the space of a few hours, or days at most. This 
effusion, caused by the synovial inflammation, generally begins to dis- 
appear within a week or ten days, and cannot usually be detected after 
the second week ; but meanwhile, pretty often, a more or less extensive 
cellulitis ensues, involving the front and sides of the knee and extending 
some distance up and clown the limb. Usually this is moderate, but it 
has occasionally, and especially when injudicious pressure has been em- 
ployed, resulted in suppuration of the areolar tissue. 



i 



436 



FRACTURES OF THE PATELLA 



§ 3. Mode of Union and Prognosis. 

The frequency with which, according to my observations, the bond of 
union has given way at some subsequent period, renders it necessary that 
I should speak of the character of the union and the prognosis relating 
to primary accidents, and the character of the union and the prognosis 
relating to secondary accidents, separately. 

1. Character of the Union and Prognosis in Primary Accidents. — 
In my published cases the bond of union is known to have been fibrous 
in one, and in no case is it known to have been bony ; but quite often it 
has been thought, when the patient was first dismissed, that the union 
was bony, and in almost every case a much later examination has shown 
that it was fibrous. When the dressings are first removed there is often 
such a degree of hardness of the tissues between the fragments as to lead 
one to suppose that the fragments have united by bone, and they are so 
fixed that they cannot be made to move separately, but which deceptive 
appearance is removed in the course of a few weeks or months. 

I do not know positively that in any case the union was by bone. If I were 
to state my convictions, I would say that probably none of the tabulated trans- 
verse fractures were united by bone ; and that only a small proportion of the 
vertical and comminuted fractures were thus united. I do not deny the pos- 
sibility of union by bone. A few cases, verified by the autopsy, have been 
reported from time to time, but I have never seen but one case verified by 
dissection. 

Bony union was for a long time considered impossible. 

Pibrac challenged all surgeons of his time to show him a patella thus united. 
Dupuytren, who thought he had obtained a union of this kind, offered for the 
patella of his patient its weight in gold. According to Velpeau, however, Wil- 
son and C. Bell had seen a case of bony union ; Lallemand had demonstrated its 
possibility, and there was a specimen of it in the Hunter museum. 

The length of the fibrous bond, in primary cases, is usually about half 
an inch, and ranges from one-quarter of an inch to five inches ; but of 

the whole number recorded by me, there are 
only four in which the new ligament is more 
than one and a half inches in length. These 
latter are, therefore, exceptional cases ; and 
were rendered so by the greater violence in- 
flicted, and the more extensive rupture of the 
aponeurosis and muscle, or by injudicious 
treatment. 

[The formation of bone in the ligamentous mate- 
rial has been noticed by Page, 1 of London. In a 
man who had fractures of both patellae many years 
previously, he found a mass of bone between the 
fragments, which was of the same width as the liga- 
ment, and seemed to be separate from the other 
portions of the patella.] 

We may appreciate where the responsibility 
generally lies, when fragments unite with so much separation, as in the following 
cases : S. H. had an abscess which had formed without any appreciable cause 



Fig. 274. 




Fracture of patella united by 
bone. (Bryant.) 



1 London Lancet, March 17, 1888. 



MODE OF UNION AND PROGNOSIS. 437 

in the areolar tissue, just above the left knee. He had an old fracture of the 
patella in the same limb, the fragments being separated nearly four inches. He 
was unable to extend the limb by muscular action, there being apparently no 
bond of union between the fragments. The accident occurred about three years 
and five months before. He was immediately taken to Bellevue Hospital. On 
the fourth day the limb was laid upon an inclined plane. On about the seventh 
day a plaster-of-Paris splint was applied, from the foot to the hip. He was per- 
mitted to go about on crutches. When the splint was removed the fragments 
were separated two inches. He has had no treatment for the fracture since. 

J. S., set. 24, was struck in the right knee while he was sitting with his leg 
bent under him. Severe inflammation and swelling ensued, and no apparatus 
was employed until the twelfth day; a compress was then laid over both frag- 
ments, and they were bound on with a roller, the limb being laid upon an in- 
clined plane. The bandages were removed at the end of four months, when the 
upper fragments at once drew up toward the body. It was eighteen months 
before he could walk without a cane. Twenty-nine years after the accident I 
found, when the limb was. straight, that the upper fragment lay two and a half 
inches above the lower, and when the limb was flexed it separated five inches. 
No trace of a ligament or other bond of union could be felt. He walked well, 
without a cane, there being very little or no halt, but he could not walk fast. 

J. M., aet. 56, broke his left patella transversely, below the middle, by a fall 
upon the knee. A surgeon was called, and applied bandages. He was four or 
five weeks in bed, and then went out, using a cane. The fragments were then 
found to be much separated. Seventeen years after the accident, I found the 
fragments separated three and half inches when the leg was straight, and 
four and three-quarters when it was flexed. Fragments of normal size. No 
ligament between the fragments ; but along their outer and inner margins 
the tendinous fibres of the quadriceps are prominent, and especially on the 
outer side. He cannot extend the leg by muscular action when sitting, but 
he can flex it to an acute angle with the thigh. Standing he can flex and ex- 
tend it perfectly. In extending he turns the foot out, in order to bring into 
action the outer portion of the quadriceps. He has always, since this accident, 
been somewhat lame, but could walk several miles and carry loads without a 
cane. May 25, 1879, he slipped and fell, striking upon the right knee, and 
breaking- the right patella transversely about its middle. June 1, a surgeon ap- 
plied adhesive strips over and above the patella, then a plaster-of-Paris bandage 
from the hollow of the foot to above the knee. Fragments were separated an 
inch or more. Began to walk. A few days later the leg suddenly gave way, 
and he fell back. The skin became discolored, and it swelled very much. When 
he consulted me the fragments of the right patella were separated one and three- 
quarters inches when the limb was straight, and three inches when it was 
flexed. He walked slowly without a cane, but was in constant fear of falling. 
I advised him to submit to a second trial to obtain a more satisfactory result in 
the case of the right leg, but he declined to do so. 

[The position of the fragments in transverse fracture should be borne in mind 
in treatment. The upper fragment is generally found tilted upward, and care 
must be taken to force it into position by the application of the bandage directly 
around the knee.] 

I have found the fragments tilted, in consequence of a yielding of the 
new ligament, or because of a pressure of the bandages, in four cases. 
In three of these it was the inner portion of the ligament which had 
given way, and in one the outer. If from so few examples it is proper 
to infer the existence of a rule, and to declare that the inner portion 
gives way most often, we may perhaps find a reason for the rule in the 
fact that the inner portion of the quadriceps is more powerful than the 
outer portion, and might therefore act more energetically upon the inner 
margin of the upper fragment, and cause it to separate more widely from 
the lower. 



438 FRACTURES OF THE PATELLA. 

Malgaigne made the same observation which I have made, and does not hesi- 
tate to speak of it as a rule, or absolute law ; declaring that it is always the inner 
portion which is found elongated ; but I have mentioned one example in which 
the fact was otherwise. Boyer also alludes to the tendency in the upper frag- 
ment to tilt outward ; and both of these writers think that the phenomenon is 
due to the manner in which the pressure of the apparel was made to bear upon 
the upper end of the upper fragment. 

The upper margin of this fragment is not horizontal, but oblique, its 
outer portion being considerably above the plane of its inner portion ; so 
that any form of adjustment in which the plane of pressure from above 
is horizontal will press more effectively upon the outer than upon the 
inner portion, and cause the upper fragment to tilt, or incline outward. 
It seems to me that both unequal muscular action and the direct but 
unequal, or maladjusted, mechanical pressure of nearly all forms of ap- 
parel employed to bring down the upper fragment, may be considered as 
alike responsible for this result. This I have sought to avoid by employ- 
ing a somewhat elastic cotton roller for the purpose of making the down- 
ward pressure. 

Occasionally it is found, when the fragments have united, that one or 
both of the fragments are inclined a little forward at the point of frac- 
ture, forming an angle salient in front. Usually it is but one of the 
fragments that is thus inclined ; and in most cases, if not in all, that 
fragment which is the longest is the one which projects. Thus, of my 
published cases, two were transverse and in the upper third, and when 
union was completed the upper margins of the lower fragments overhung 
the lower margins of the upper. The longest fragment resting upon a 
convex surface, and being no longer held in position by a counter-force, 
the ligamentum patellae or the quadriceps must inevitably incline for- 
ward. Indeed, I have seen this condition present in a recent fracture 
before any apparatus had been applied ; but in such cases very slight 
pressure, applied from before backward, was sufficient to restore it to 
place ; and it is quite certain that for this result after union is consum- 
mated, the apparatus employed to bring the fragments together is mainly 
responsible. Both the quadriceps and the ligamentum patellae have 
their insertions nearer the anterior than the posterior margins of the 
patella, a thin layer of tendinous fasciculi actually traversing its anterior 
face. The upper and lower margins of the patella, therefore, present no 
elevations for the application of concentric pressure ; and if by any form 
of apparatus concentric pressure is made, it must be accomplished by 
causing a depression in these firm ligamentous bands, or a recession from 
the tegumentary surface, in order that the concentric forces may have a 
point d appui. This pressure must depress the corresponding margins 
of the two patellar fragments, and elevate their broken margins; and in 
this case the longest fragment will suffer the greatest displacement. 
Both these displacements, namely, the tilting and the forward projection, 
are imperfections which contribute their proportion to the subsequent 
maiming ; causing, in the one case, a relative loss of strength in the 
ligament, and in both cases causing some irregularity in the movements 
of the patella over the surface of the femur. 

There is another form of displacement to which I have not yet referred, 






MODE OF UNION AND PROGNOSIS. 439 

but which seems in most cases to be temporary, although it is probable 
that it is not in all cases — namely, a simple lateral displacement. This 
existed in one case before the treatment was fully terminated. The upper 
fragment was found displaced inward one-quarter of an inch, and it 
could not be moved from this position — at least not without greater force 
than it seemed proper to apply. In this case, however, the fragment 
subsequently, when he had used the limb some time, gradually loosened 
and resumed its natural position. 

I think the same happened in one or two cases, and that they subsequently 
came into line. Probably in each case it was caused by the lateral pressure of 
the bandage, or of other parts of the dressing, and might, therefore, have been 
avoided. It is easy to imagine that if the fragments are thus displaced the bond 
of union maybe imperfect or unequal on the two sides, or that it might diminish 
the chances of union, and in either case the evil results might be permanent and 
serious. 

Hypertrophy of the fragments must be distinguished from an exostosis, 
such as is frequently observed along the margins of the fracture, and 
which is never considerable, only causing a slight irregularity in the sur- 
face of the bone, but which may be present without any peripheral enlarge- 
ment or expansion of the fragments. 

This actual hypertrophy has been observed by me in nine cases, namely, twice 
in the upper fragment alone, once in the lower fragment alone, and six times 
in both. The occasional hypertrophy of the fragments has been noticed by other 
writers, and Malgaigne has furnished two illustrations. The same thing is 
known to happen pretty often in some of the long bones when broken near their 
extremities, where the structure is cancellated. I have noticed it often in the 
fracture of the humerus near its lower end, the lower fragments being in all such 
cases the ones which become hypertrophied. In the case of the humerus the 
hypertrophied fragment, sometimes after many months or years, is found to 
diminish ; but whether such a gradual diminution in size takes place in exam- 
ples of hypertrophied patellae I am not certained. It has not seemed to me that 
it does occur. 

(a) Period required for Recovery of the Perfect Use of the Limb. — 

More or less loss of freedom in the motions of the joint, and of strength 
and stability in the limb, remains in the majority of cases for a long 
period of time, and often during life. In a few exceptional cases, where 
the separation does not exceed one inch, the functions of the limb are 
completely restored within one or two years. It is remarkable, also, how 
well the functions are restored, after a long time, in some cases where the 
separation is very great. 

Malgaigne says : " Camper has stated that in one or two years the power is recov- 
ered, whatever may have been the intervals between the fragments ; an evident 
exaggeration, since he speaks of a lady with a separation amounting to three fin- 
gers' breadth, who still limped four years after the receipt of the injury. Mr. Ben- 
jamin makes one inch the line of separation, allowing for the restoration of the 
firmness of the knee ; Boyer follows him ; M. Velpeau, on the contrary, affirms 
that he has seen the functions of that joint completely reestablished, with an 
interval of two or three inches between the fragments. Such assertions are, in 
my opinion, only accounted for by some inaccuracy of examination, and for my 
own part I have never seen the functions of the limb completely restored, even 
when the separation was limited to one-third of an inch." 1 For myself, I have 

1 Malgaigne, op. cit., p. 606. 



440 FRACTURES OF THE PATELLA. 

seen three or four perfect results, so far as the use of the limb is concerned. In 
one case, after nineteen years, there was not the slightest difference in the 
freedom of use of the two limbs ; yet the union is by a ligament of three-quarters 
of an inch in length. 

The first and main impediment in the restoration of the functions of 
the joint is the ankylosis, which is, in many cases, at first nearly com- 
plete. This ankylosis is due to the passive contraction of the articular 
ligaments, as a consequence of long disuse ; to adhesions and inflamma- 
tory infiltrations among the torn muscular and tendinous fibres ; and 
between these latter and the upper fragment of the patella as it lies more 
or less buried in the torn tendinous tissues. It is never safe to attempt 
to overcome this ankylosis by force, consequently the process of restora- 
tion must be slow and uncertain, and it will generally be found to be 
many years before the leg can be flexed upon the thigh to the same angle 
as in the case of the opposite limb. 

[The impairment of the function of the limb must be in part ascribed to the 
wasting of the quadriceps. Verneuil attributes it to atrophy of the rectus fem- 
oris. Richelot ( Union Medicale, 1882) thinks this atrophy is due to the arthritis 
which accompanies the fracture of the patella. Whatever may be the cause of 
the atrophy the indication in treatment is apparent, viz. , that early efforts should 
be made to improve the condition of the quadriceps, as by massage.] 

In a certain degree, also, the changed relations of the fragments to the 
articular surface of the femur may be responsible for the lameness. As 
to what influence the nature and length of the new bond of union have 
upon the usefulness of the limb, I am prepared to say, first, that the fact 
that it is generally fibrous and not bony is probably of no consequence, 
provided the bond of union does not exceed one inch in length. It cer- 
tainly is in no way responsible for the ankylosis ; and, as to its effect 
upon the stability or strength of the limb, there is no reason to suppose 
that this slight diminution in the range of the contraction and elongation 
of the quadriceps will have, after one or two years of use, any appreciable 
effect upon the stability of the limb. Indeed, so far as I have been able 
to ascertain, in most of these cases the patients have been able, after a 
time, to extend the limbs as completely if not as forcibly as before. If, 
however, the length of the fibrous bond is much more than one inch, 
there is generally an appreciable loss of the power of complete and fixed 
extension. 

We have had recorded too few well-attested examples of bony union to enable 
us to declare whether the fibrous union or the bony union is most liable to a 
secondary accident — a refracture. It would seem reasonable to suppose that 
the newly-formed bone would be thinner than the original bone and less spongy, 
and that in consequence of its compactness and thinness it would break more 
easily under a cross-strain than would an equally thick, but flexible, ligament. 

Dr. Kendig, of Ohio, has kindly sent a specimen to me in which union of the 
two fragments of the patella has taken place by means of two thin plates of bone, 
corresponding to the inner and outer margins of the patella, leaving between 
them an open space, which in the recent state was probably Occupied by fibrous 
tissue. Of the two plates which compose the bond of union, the inner is much 
the larger. It is evident, upon the most superficial examination, that the least 
flexion of the limb would have been sufficient to cause a rupture of the bony 
callus ; indeed, the outer plate was broken and partly destroyed in cleaning it. 






MODE OF UNION AND PROGNOSIS. 



441 



My conviction is that a fibrous union of less than one inch in length is quite 
as advantageous as a bony union, and probably much stronger — a conviction 
which is enforced, also, by a case of Dr. Little, of this city. A fractured patella 
united by fibrous tissue with a separation of half an inch. About five and a half 
months later the same patella was fractured at a point about half an inch above 



Fig. 275. 



Fig. 27*5. 





Dr. Kenclig's case of bony union after a fracture of the patella. (From author's collection.) 
Front view. Side view. 

the first fracture and transversely. This united also by fibrous tissue of the 
same length as the first. The three fragments were movable upon each other, 
and no doubt can exist as to the character of the accident. In this case at least, 
then, after the lapse of a little more than five months, the new ligament has 
proven itself to be stronger than the original bone. 

(b) Rupture of the Newly-formed Ligament. — In the prognosis of 
original fractures we have to include the danger of a rupture of the 
newly-formed bond of union. Indeed, my statistics, already referred to, 
show a startling frequency of this accident. It is known to have oc- 
curred in twenty-five cases, and in two additional cases the ligament has 
given way partially. A knowledge of this fact is of the greatest impor- 
tance, as indicating the necessity for great care in the use of the limb 
after the surgeon has practically dismissed the patient. 



Some of these cases were persons who sought my advice only after the treat- 
ment had terminated, and they might not therefore correctly represent the true 
proportion in a given number of consecutive cases. On the other hand, it will 
be remembered that a considerable number of the one hundred and twenty-seven 
tabulated cases were not seen or heard from by me, after the treatment was ter- 
minated ; so that, on the whole, I think that twenty-seven out of every one hun- 
dred and twenty-seven represents fairly the average ratio of these accidents. 

It is reassuring to know that two-thirds of the whole number were ruptured 
very soon after leaving off the apparatus ; that is, within ten weeks after the 
original fracture had taken place ; and that five of these took place gradually, 
commencing when the patient began to walk. Only two occurred later than 
five months after the injury, or about three months after the apparatus was 



442 



FRACTURES OF THE PATELLA. 



removed. It would seem, therefore, that it is only necessary to provide against 
the accident during the first three months after removal of the splint, and that 
after this a rupture is no more likely to take place than if it had not been broken. 



Fig. 277. 




Fracture op Jan. 1879. 




Fig. 277 represents the position of the fragments after two successive fractures, in the 
person of Dr. E. Cutter, of New York, examined by the author in 1884. Actual size. 
Fragments united by ligament. The shaded lines represent new bone. 



(c) Fracture of the opposite Patella. — This has happened five times 
in the one hundred and twenty-seven cases, and was no doubt due in each 
case to the greater effort made by the quadriceps of the sound limb to 
sustain the body, when the equilibrium of the body had been disturbed. 

2. Character of the Union, and Prognosis after the Secondary Acci- 
dent. — A majority of cases refuse to unite again, even by fibrous tissue, 
whatever means may be employed ; and the few cases of union after 
rupture of the fibrous bond which have come to my knowledge, are con- 
fined almost entirely to those examples in which the rupture took place 
very soon after the apparatus was removed, and in which the limb was 
immediately subjected to treatment. When the fragments do not unite 
the patients are for a long time seriously maimed, the limb lacking 
stability, and often giving way suddenly under the weight of the body. 
In most of these cases, however, a judicious treatment will eventually 
give considerable stability to the limb, and enable the patient to walk 
with much safety and ease. 



TREATMENT OF FRACTURES OF THE PATELLA. 443 



§ 4. Treatment of Fractures of the Patella. 

Treatment, in Primary Accidents. — Our investigations have brought 
us to conclude that in a large majority of cases, under any plan of treat- 
ment, a fibrous union of the fragments is all that can be expected ; and 
that probably a fibrous union, with only a separation of a half or three- 
quarters of an inch, is as useful as a bony union. Probably more useful. 
The only methods which could encourage a reasonable hope of procuring 
a bony union, are Malgaigne's hooks, and wiring the fragments together. 
Malgaigne's hooks have hitherto not been proven to accomplish this 
result, not even in the hands of the distinguished inventor. In fact, 

Fig. 278. 




Malgaigne's hooks. 

contrary to what I would have expected, there have been among the cases 
reported as many examples of fully-recognized fibrous union, as have 
occurred where some other plans of treatment have been followed ; the 
fibrous band has been no shorter ; and the number of cases in which a 
bony union has been said, but not proven, to exist soon after the removal 
of the apparatus, is no greater than almost every other method has sup- 
plied. On the other hand, several cases have been reported of dangerous 
or disastrous inflammation induced by the hooks, and to this objection 
many other methods are never liable. There seems no possible reason, 
therefore, why in any ordinary, simple transverse fracture, in which the 
original separation does not exceed one inch or even one and a halt 
inches, the hooks should be employed ; but in cases in which the original 
separation exceeds this, and especially in cases of a refracture or rupture 
of the fibrous bond, accompanied with great separation, it is my opinion 
that Malgaigne's hooks are entitled to a further trial. 

[The opinions of surgeons in regard to the dangers of Malgaigne's hooks, and 
their value, have been greatly modified since the introduction of antiseptics into 
practice. They are now used antiseptically without inflammation. At a meet- 
ing of the Harveian Society, London, in 1888, Mr. Silcock presented a patient 
treated by Malgaigne's hooks in which he considered that bony union had been 
obtained. Antiseptics were used. Mr. Treves considered them an almost per- 
fect method of treatment, although it was difficult to obtain properly manufac- 
tured hooks. Mr. Wm. Adams thought this method gave excellent results and 
did not injure the joint. All who use them insist upon the most careful atten- 
tion to the antiseptic precautions. The limb must be thoroughly cleansed, the 
parts shaved and treated with sublimate douches ; the instrument must be placed 
in carbolic acid solutions ; the punctures must be made for the teeth with a teno- 
tome ; the knee must be dusted with iodoform.] 

"That Malgaigne's hooks," says Volkmann, "have caused ulceration of the 
joints and death of the patient in a number of cases, is only too true; I know 



444 



FRACTURES OF THE PATELLA 



of two which occurred in the practice of friends, and which were never pub- 
lished ; and another sad experience was met with in my own clinic a number of 
years since." 1 A death occurred in a London hospi- 
tal from the use of these hooks. 2 The modification of 
Malgaigne's method suggested by Valette, of Lyons, 3 
in the substitution of adjustable forks for the hooks, 
does not render the apparatus less liable to do harm. 

Farther modifications of the apparatus have been 
made by Levis, of Philadelphia, Verneuil, Le Fort, 
and Trelat, but without materially diminishing the 
possible or probable danger. 

[Levis separated the hooks (Fig. 279), and Trelat 
fixed the hooks in gutta-percha splints (Fig. 280). 
These modifications will be understood by the illus- 
trations.] 

Severin was the first to suggest exposing the bone 
" by an incision, so as to refresh the surfaces directly ;" 
u which happily," says Malgaigne, " was not done." 4 

[Stimson, 5 of New York, has employed a " coapta- 
tion fork," which is of iron, two-pronged, the prongs 
bent on the flat at an angle of about 45° at their junc- 
tion with the shaft ; the prongs are one inch long 
and three-fourths of an inch apart ; the shaft is about 
three inches long ; there is a small ring at the base of 
the prongs for the attachment of a rubber cord, and 
another at the end of the shaft for the attachment of 
a bandage encircling the thigh. The instrument is 
used by inserting the prongs through the skin above the patella and pressing 
them down until they rest against the upper border of the upper fragment; the 
shaft lies along the median line of the front of the thigh, and is prevented from 
tilting or moving to either side by a roller bandage wrapped around it and the 




Levis's hooks in position. 




Trelat's method of applying hooks. 

thigh. Traction downward is made by a piece of rubber tubing one end of which 
is attached to the ring at the base of the prongs, and the other made fast to the 
front of the shin by adhesive plaster. The introduction of the prongs is made 
after chilling the surface with ice, and making punctures of the skin with a knife. 
The punctures are dusted with iodoform. The lower fragment is kept gently 
pressed forward by an oblique turn of a roller bandage.] 

[W. K. Otis, 6 of New York, has devised a new form of hooks (Fig. 282), which 
is designed to remedy some of the defects of Malgaigne's hooks. Its peculiarities 



1 Volkmann, Cent. f. Chir., 1880,24. 2 London Lancet, Nov. 22, 1879. 

3 Valette, Poinsot, French ed. of this treatise, p. 611. 

4 Severin, Chir. efficacis, part ii. chap. vii. Malgaigne, op. cit , torn. i. p. 775. 

5 Amer. Surg., St. Louis, vol. i. 1885. 

6 New York Med. Journ., Dec. 31, 1889. 



TREATMENT OF FRACTURES OF THE PATELLA. 445 

will be understood from the illustration. It is applied as follows : An ordinary 
straight posterior knee-splint having been applied, and the knee and instrument 
rendered thoroughly aseptic, the movable pair of hooks are adjusted to fit one 
fragment and firmly clamped to the cross-bar. Four punctures are made with 
a tenotome, or small bistoury, through the integument down to the bone, at 
points corresponding to the insertion of the hooks. The hooks having the set 
screw (a) are removed from the bar and adjusted, the points being passed through 
the punctures and pressed into the bone. The second pair are applied to the 

Fig. 281. 




Otis's hooks for fractures of the patella. 

other fragment in a similar manner ; the fragments are now brought together as 
near as possible by manual force, the main bar is slipped through the slot on the 
cross-bar of the first pair of hooks and clamped in position by a turn of the 
screw (a) ; any separation which may still exist may be overcome by the thumb- 
screw (c).] 

Norris 1 knew of one case in which the fragments were exposed and approxi- 
mated by wire (Dec. 1842), and the patient died on the fourth day. Dr. J. Rhea 
Barton, of Philadelphia, operated in the same manner and his patient died. 2 
Dr. Moses Gunn, of Chicago, lost his patient from suppuration. 3 Dr. Cabot, 4 
of Boston, had the same result. Cooper 5 and Logan, 6 of San Francisco, made 
a similar operation, and Dr. Byrd 7 says it was made "many years ago" by Dr. 
George McClelland, of Philadelphia. The precise dates and results of the three 
latter operations are not published. Since the introduction of Mr. Lister's anti- 
septic treatment it has been thought, by some, that the operation of exposing 
and wiring the fragments together could be made with more safety. The opera- 
tion, under antiseptic precautions, has therefore been lately practised by a con- 
siderable number of surgeons. 

[The primary treatment of simple fracture of the patella by wiring the frag- 
ments must be regarded as still unsettled. It is true that the operation has but 
few advocates, yet it is by no means wholly discarded even by those who would 
not recommend it as a method of general application. Exceptional cases occur 
which invite to its performance, especially in hospital practice. The most recent 
and instructive contribution to the subject is a paper by Dr. Charles Phelps, 8 of 
New York, which is based on 42 operations by himself. Antiseptic precautions 
were carefully taken in each. The following facts are gathered from the table 
in this paper : males 82, females 10 ; ages averaging from 21 to 83 ; right 15, left 
27 ; intemperate 15, temperate 19, not given 8 ; physique good 24, bad 18 ; com- 
plications none 31, local poisoning by hyd. perchlor. dressing 3, rupture of 
quadriceps extensor muscle 2, non-union of previous fracture of same patella 2, 
typho-malarial fever and phlegmonous erysipelas 1, periostitis 2, septicaemia and 

1 Norris, Amer. Journ. Med. Sci., Jan. 1842, p. 51. 

2 Barton, Gross's Surgery, 5th ed., vol. i. p. 1004. 

3 Gunn, Wyeth's paper, Med. Record, July 3, 1882. * Cabot, Ibid. 

5 Cooper, San Francisco Med. Press, 1861. 

6 Logan, Pacific Med. and Surg. Journ., Dec. 1866. 

7 McLelland, New York Med. Journ., Dec. 1866. 

8 New York Med. Journ., vol. li., 1890. 



446 FRACTURES OF THE PATELLA. 

diffused inflammation 1 ; immediate results — firm or bony union and good use of 
limb or joint 38, bony union 3 (of which 1 had flexion 15°), ankylosed 1, flexion 
not begun 1 ; fragments could not be coaptated 1 (ankylosed and strong limb) ; 
definitive results — -bony union 41 (ankylosed and strong limb 1) ; condition of joint— 
perfect 27, ankylosed 2, flexion 90° 4, 45° 1, 40° 1, 30° 1, 15° 1, limited 1, not 
begun 1, not given 3. The period at which patients were seen after the opera- 
tion varied from one month to five years ; after one year 24. There was no 
death. Of the 24 cases seen after one year, all are reported as having bony 
union. 

If these statistics are compared with those compiled by Prof. Hamilton, and 
summarized in preceding pages, and also by Brunner, Beck, and Bull, illus- 
trating the results of non-operative treatment, several Conclusions of importance 
will follow. 1. Though there is no death reported in either group of cases, the 
complications resulting from this operation in reported cases are more serious. 

2. Bony union, and hence a firm joint, is far more likely to follow the operation. 

3. Impairment of the joint by time and use is far more frequent in non-operated 
cases. 4. B-efracture, or rupture of the uniting medium, is more liable to occur 
in non-operated cases. 5. Ankylosis of joint is more frequent in operated cases. 

These comparisons lead to the conclusions : 1. That the average results of the 
operative and non-operative treatment of fractures of the patella, in the cases 
which do well, are largely in favor of the operative method, owing to the fact 
that, as a rule, bony union is secured by that method, and ligamentous union 
by the non-operative treatment. While it is abundantly proved that liga- 
mentous union is not incompatible with a serviceable limb, it is nevertheless 
equally proven that bony union gives the most stable joint, and for the longest 
period. Bony union in fracture of the patella is the result which we seek, and 
which we regard as the perfection of cure. 2. The operative method is liable 
to be complicated by accidents which do not occur in the non-operative treat- 
ment. These accidents have for the most part resulted from simple defects in 
the details of treatment easily avoidable. 3. The period of recovery is much 
less in the operated than in the non-operated cases. Laboring men have re- 
sumed work, Dr. Phelps remarks, when patients treated by other methods are 
still in bed, or, at least, on crutches ; in two instances patients resumed heavy 
work within six weeks of the operation ; one in two months ; and many others 
during the third month. Prof. Hamilton states that in non-operated cases the 
bond of union may be considered complete in six or eight weeks, but that for 
the next three or four months the patient should walk only upon crutches, and 
the knee-joint should be constantly supported unless it is completely at rest. 

The following conclusions of Dr. Phelps appear to be the logical deductions 
from all the facts which he has presented: 

" 1. Osseous union is prevented by the intervention of aponeurotic fibres 
between the fragments, and becomes possible only after their removal by an 
operation which involves opening the joint. 

" 2. In recent refractures after wiring, and in very exceptional primary frac- 
tures, these fibres do not intervene, and osseous union can be obtained without 
operation if coaptation of the fragments can be otherwise effected and main- 
tained. 

" 3. Osseous union is always obtained after removal of these fibres and coap- 
tation or close approximation of the fragments by wiring. 

" 4. There is no danger to life in this operation from sepsis or articular sup- 
puration, provided aseptic laws are fully observed, and no greater danger from 
accidental complications than in trivial forms of surgical interference. 

" 5. There is no danger of osteitis or necrosis. 

" 6. There is no danger of ankylosis if proper care be taken in the use of 
passive motion, and if in certain cases forcible flexion under ether be employed. 

" 7. There is less danger of refracture, or of subsequent fracture of the opposite 
patella, than when union is by ligament. 

" 8. The treatment by this operation is less fatiguing to the patient, requires 
a shorter period of confinement in bed, and enables him to walk and to resume 
his occupation sooner than any other method of treatment.'' 

The surgeon who contemplates this operation should remember the injunction 
of Sir J. Lister, viz.: "No man is justified in performing such an operation 






TREATMENT OF FRACTURES OF THE PATELLA. 447 

unless he can say with a clear conscience that he considers himself morally cer- 
tain of avoiding the entrance of any septic mischief into the wound." 

The operation is as follows : All the materials used are of known aseptic 
quality ; the instruments are constantly kept in carbolic solution, 1 to 20, except 
when actually in use; the surgeon and assistants are thoroughly prepared by 
antiseptics ; the room is clean and free from septic matter. Proceed as follows : 
1, wash the limb thoroughly with soap and water from the foot to the hip; 2, 
shave the knee from three inches below to the same distance above the fracture ; 
3, douche the entire limb with bichloride solution 1 to 2000 ; 4, wrap the limb 
above and below the knee with towels wet with bichloride solution ; 5, with 
knife taken from a carbolic solution make a transverse incision in the line of 
fracture exposing the fragments ; 6, douche the wound frequently with bichloride 
solution 1 to 4000 ; 7, clean the fractured surfaces of blood-clots, and with scissors 
clip away all shreds of membrane which are liable to fall between the bones ; 

8, with bone-drill or a brad-awl make a hole through the fragments at the 
centre, obliquely, entering the bone anteriorly, not to exceed half an inch from 
the margin, if there is space, and emerging near the posterior articular surface ; 

9, pass the wire and twist it while an assistant presses the fragments firmly 
together; 10, cut the wire ends, leaving three-eighths of an inch of the twist, 
and bend this over and bury it between the fragments ; 11, with carbolized cat- 
gut stitch the deep fibrous structures, with a continuous suture, firmly together ; 
12, place in each angle of the wound a small drain, or if the angle forms a 
pocket, as is generally the case, make an opening, at its lowest part, through the 
skin and apply the drains, which should nearly or quite meet at the highest 
part of the wound ; 13, close firmly the external wound throughout with pre- 
pared silk suture; 14, douche the knee with the solution and throw it into. the 
drains to prove that they are open ; 15, dust the wound and knee liberally with 
iodoform, and surround the knee with mussed bichloride gauze several inches 
in thickness; 16, over this, and extending from the foot to the hip, apply a 
thick layer of prepared sheet cotton well sprinkled with iodoform ; 17, over all 
apply a plaster bandage three thicknesses ; or first place the limb in a wire 
cradle, and then apply plaster-of-Paris bandages ; 18, on the third to the fifth 
day make small openings at the site of the drains and remove them, injecting 
their tracts with the bichloride solution, and closing the opening with iodoform 
and cotton.] 

Kocher, recognizing the dangers attending the use of bony sutures, substituted 
a metallic suture which, by means of a curved needle, was passed under the 
upper and lower margins of the fragments and secured in front of the patella by 
twisting the extremities. It is difficult to see how this method should materially 
diminish the dangers, as the suture, or ligature more properly, " is drawn through 
the joint." (Volkmann.) 

[Laplace, 1 of New Orleans, was led to perform an operation very similar to 
Kocher's, with good results, by the breaking of the drill with which he was 
wiring the bones.] 

Volkmann 2 says : " Long before the introduction of antisepsis I attempted 
suture of the tendons in fracture of the patella, and though the ligature was left 
in place only a very short time, until the plaster-of-Paris bandage which was at 
once applied- had hardened, I twice met with very satisfactory success. The 
two cases were described in Virchow's and Hirsch's Jahresbericht, f. 1868, Bd. 
ii. p. 364. ' In two cases I drew through the tendon of the quadriceps and the 
ligamentum patellae, while the integument was strongly retracted, at first in an 
upward, then in a downward direction, a simple loop of thread, and knotted 
the same over the patella ; by this means the fragments were brought into con- 
tact, and at the same time the prominent edges were depressed. Then a very 
tightly fitting plaster-of-Paris bandage was applied, and directly after it had hard- 
ened, a fenestra as large as a two-cent piece was cut into it, corresponding to the 
spot where the ligatures had been tied, and the latter were cut and withdrawn. 
In one case, firm osseous union resulted ; in the other, a very narrow, fibrous, 
intermediate substance was formed ; in a third case, one of my clinical assistants 

1 Trans. Louisiana State Med. Societv, 1889. 

2 Volkmann, Centralb. f. Chir., 1880, 24. 



448 FRACTURES OF THE PATELLA. 

applied the bandage in the same manner, and though the ligature was removed 
after remaining in place hardly a quarter of an hour, ulceration of the articula- 
tion and death from pyaemia ensued.' The autopsy showed that in this unfor- 
tunate case the ligature had been introduced too deeply, and transfixed the 
joint, and that the- plaster dressing had not been padded, but applied directly to 
the limb after enveloping the latter in moist blotting paper. More recently I 
repeated the above operation with some slight variations, and the result was all 
that could be desired." 

Volkmann 1 advises opening the joint for the purpose of evacuating the ex- 
travasated blood ; but Kocher calls attention to the fact that the blood has been 
found coagulated as early as the third day, and he thinks, therefore, that the 
opening ought to be made as soon as possible. Schede 2 proposes to wash out 
the joint with carbolized water; but Kocher says he has seen this produce car- 
bolic-acid poisoning. 

Lastly, it is proposed to aspirate the joint for the purpose of evacuating 
the synovial fluids, and thus relieve the distention which tends to separate 
the fragments. The objections to this procedure are that it is not unac- 
companied with danger ; but the joint will, in most cases, become speedily 
refilled ; that usually the effusion begins to be absorbed as early as the 
seventh day and soon disappears entirely, so that practically it does not 
seriously interfere with the process of union. 

In a case aspirated by Dubrueil 3 purulent arthritis ensued, but the final result 
is not given. In a case reported by Dr. Robert McDonald, 4 aspiration of the 
knee-joint having been made for chronic effusion, inflammation ensued ending 
in death on the seventh day. And in the same manner Dr. George H. Ham- 
mond, one of the house staff at Bellevue Hospital, lost his life in 1881. 5 

Cutting the quadriceps demands a very extensive subcutaneous inci- 
sion, and I venture to say that no surgeon has divided all of its fibres, or 
even the fibres of the rectus, in his subcutaneous incision, and certainly 
not without carrying his incision freely into the upper part of the joint. 
The method of injecting between the fragments fresh marrow cells, has 
as yet yielded no results. Nor do I think it is likely to succeed for 
many reasons, and especially because the "germs" cannot be placed 
actually between the fragments without being in the cavity of the joint, 
where of course they could serve no purpose. To place them in the thin 
tegumentary covering, which alone remains, when the separation exceeds 
half an inch, would be, I think, equally useless. 

[A. W. M. Robson 6 reports a case treated as follows : First he aspirated the 
joint and removed the blood and serum. Then he took two long steel pins, with 
glass heads, such as ladies use to fasten on their bonnets. One of these, thor- 
oughly purified, was pushed from without inward through the quadriceps tendon 
and out on the opposite side, immediately above the upper fragment, the skin 
being first drawn upward. The other pin, properly prepared, was passed in like 
manner through the upper end of the ligamentum patellae, just below the lower 
fragment. Gentle traction on the pins brought the fragments into contact. A 
suture of aseptic silk was next passed in the form of a figure-of-eight around 
the pins. The ends of the pins were cut off and antiseptic dressings applied. 
A straight splint was applied to the posterior part of the leg. This dressing 

1 Volkmann, Kocher, loc. cit. 2 Schede, Centralb. fiir Chir., 1877, p. 657. 

3 Dubrueil, Bull, de Soc. Chir., Oct. 1872, p. 438. 

4 McDonald, Amer. Journ. Med. Sci., April, 1873, p. 548; from Irish Med. Gaz. 

5 Medical Record, June 11, 1881. 

6 Trans. Clinical Society of London, vol. xxii. 






TREATMENT OF FRACTURES OF THE PATELLA. 449 

was continued three weeks, when the pins were removed and a plaster-of-Paris 
dressing substituted. The result was in every respect satisfactory.] 

Finally, in order to accomplish the best results with the least possible 
danger to life or limb — that is, to produce the shortest ligament, while 
the complete integrity of the joint is preserved — there are presented four 
simple indications of treatment, namely : 

First. Approximation of the lower fragment to the upper by straight- 
ening — extending — the leg upon the thigh. 

Second. Securing immobility of the knee-joint by a splint. 

Third. Relaxation of the quadriceps muscle. This indication is ac- 
complished in a small degree by flexing the thigh upon the body ; but 
the effect of this posture is not so great as some writers have supposed. 
The quadriceps has but one origin from the pelvic bones, and conse- 
quently flexion of the thigh does not very greatly relax its muscular 
fibres. Yet that it possesses some value in this direction is easily demon- 
strated by experiment. The quadriceps is chiefly relaxed by extending 
the leg upon the thigh ; that is, by placing the limb in a straight position 
and maintaining it in this position. 

The fourth indication is to approximate the fragments by direct pres- 
sure ; so far as this can be done, without inflicting serious injury upon 
the integument, or other structures. Without this pressure the relaxation 
of the muscle will not bring the fragments into actual juxtaposition, or 
even make them approximate this condition. In order to make direct 
pressure, surgeons have devised a great variety of methods ; most of 
which are liable to the serious objection that they press too tightly upon 
the entire circumference of the limb to render them perfectly safe under 
all circumstances ; and especially when the opposing forces, which are 
intended to approximate the fragments, are applied with the view of 
securing absolute coaptation, as many of the inventors declare to be their 
intention. 

That danger exists from this source, the following case will illustrate : " A 
vine-dresser, set. 40, received a simple transverse fracture of the patella. The 
medical officer applied first a bandage, for the purpose of drawing together the 
fragments, and afterward a starched bandage, extending from the toes to the 
upper part of the thigh. The limb was placed upon an inclined plane. The 
patient was visited a few times, but, as he scarcely suffered, the apparatus was 
in no way disturbed. On the sixteenth day the attendant returned to remove 
the bandage, -when the odor arising from the limb led him to believe that gan- 
grene had taken place." The bandage being removed, the gangrene was found 
to extend to within seven inches of the knee. The ankle-joint was opened and 
the ligaments destroyed. The bones of the leg were also exposed in their lower 
third, and the tendons were in a sloughy state. Amputation was performed, 
and the patient recovered. 1 In one of my published cases, plaster-of-Paris had 
been upon the limb one week when gangrene was threatened, and the plaster 
had to be removed. Two other cases illustrate the danger also of tight bandages 
in causing gangrene after a fracture of the patella. 

Dr. Dorsey, of Philadelphia, employed an apparatus which will serve to illus- 
trate in its most simple form the principle of approximating the fragments by 
the use of a splint and bandage. His apparatus consisted of a piece of wood 
half an inch thick and two or three inches wide, and long enough to extend 

1 Araer. Journ. Med. Sci., vol. xxiv. p. 462, from Gaz. Med., No. 28. 

29 



450 



FRACTURES OF THE PATELLA. 



from the buttock to the heel ; near the middle of this splint, and six inches 
apart, two bands of strong doubled muslin, a yard long, are nailed. The splint 

Fig. 282. 




John Syng Dorsey's patella splint. 

is then cushioned, and the limb laid upon it, a roller being first applied from 
the ankle to the groin, encompassing the knee in the form of the figure of 8 ; 
after which the two muslin bands are secured across the knee in such a manner 
as that the lower one shall draw down the upper fragment, and the upper one 
elevate the lower fragment. 
Mr. Lonsdale devised a very complicated apparatus. 

Fig. 283. 




Lonsdale's apparatus for fractured patella. — A B. Two vertical iron bars, each supporting 
a horizontal one; these horizontal arms slide upon the vertical bars, but can be secured at 
any point by the screws CD. To the horizontal beams are attached other vertical rods> 
which are movable, and yet fixable by screws, as at E. Finally, to each of these last upright 
pieces is fixed an iron plate, F F, by means of a hinge-joint, which keeps the patella in place. 
The foot-piece is movable up and down upon the main body of the apparatus, and can be 
made fast at any point, so as to adapt the splint to limbs of different lengths. 

Sir Astley Cooper employed two methods of approximating the fragments, 
which will be sufficiently illustrated by the following woodcuts : 



Fig. 284. 




Sir Astley Cooper's method by circular tapes. 



TEEATMENT OF FRACTURES OF THE PATELLA. 451 

Fig. 285. 




Sir Astley Cooper's method by a leather counter-strap. 

The apparatus devised by Lausdale, U. S. N., is more simple than Lonsdale's, 
but both of them can only approximate the fragments when they press very 

Fig. 286. 




Lausdale's apparatus. 

firmly, and then they will necessarily tilt the fragments and expose the patient 
to the risk of ulceration at the points of pressure. This happened in the only 
case which I have seen which had been treated by Lausdale's apparatus on the 
fifth day after it was applied. This is the case of Assist. Surg. Meyers, reported 
near the close of this chapter. In neither of these forms of apparatus can band- 
ages be properly applied to restrain the tilting of the fragments, and to give the 
knee-joint' a smooth and equal pressure when it is swollen, as it usually is. 

The apparatus of Beach, of Illinois, is liable to the same objection. 1 The de- 
vice of Burge, of Brooklyn, in which the fragments are approximated by care- 



Wires in semicircular form {A), the posterior part 
of each segment (_B) being curved upward and the 
sides a little depressed. A shoulder is formed (C) on 
each side of the segments for the reception of the 
two straps (D), which connect them, and projects far 
enough on each side to permit the wires to be bent 
downward at right angles with the shoulder, and 
descend perpendicularly to the slot or mortise (E) 
which is placed near each end of the block (F). 



Beach's apparatus. 

fully-adjusted leather pads, operated upon by weights, cords, and pulleys, is too 
complicated, and possesses no marked advantages over the simple roller employed 
in my own dressing. 2 




1 Beach, St. Louis Med. and Surg. Journ., Jan. 1875. 

2 Burge, Med. Record, April 15, 1868. For illustrations see 5th ed. 



p. 471. 



452 



FRACTURES OF THE PATELLA. 



Fig. 288. 




Beach's apparatus applied. 

The apparatus of Dr. Turner, 1 of Brooklyn, and of Dr. John A. Wyeth, of 
this city, involve the same principles, and are equally liable to objections, on 
account of the limited surface against which the pressure is made. 

Fig. 289. 




Turner's apparatus. 

[Parker, 2 of Ithaca, N. Y., had gold screws made with which he fastened the 
fragments together, the screw passing from below upward through the lower 
fragment into the upper. The result was very firm union. 

Beach and Newell (of the Mass. Gen. Hosp.) have recently "illustrated the 
dressing preferred by them. The essential features are a long ham splint and 
coaptation splints over the quadriceps firmly bound on the thigh. The authors 
state that this method is distinguished from others by its simplicity and the 
more direct application of control to the action of the great patellar muscle, the 
contraction of which determines, provided the leg be kept straight, the degree 
of separation of the fragments. 3 ] 

Gibson, of St. Louis, has revived, in a modified form, the circular ring of 
Albucasis. 4 Drs. Eve, of Nashville, and Blackman, of Cincinnati, have spoken 
favorably of this method. 5 Its application must, however, be limited to such 

1 Turner, Medical Record, July, 1867. 2 The Polyclinic, Feb. 15, 1885. 

3 Medical Record, Mar. 15, 1890. 

4 Gibson, Araer. Journ. Med. Sci., Jan. 1867, p. 281. 

5 Eve, Blackman, Nashville, Journ. Med., February, 1867; Western Journ. Med., 
May, 1868. 



TREATMENT OF FRACTURES OF THE PATELLA. 453 

cases as are unattended by inflammation, and can tolerate the pressure applied 
only to a small point of the surface. It is essentially the same as Beach's appa- 
ratus, but has the advantage of being more simple. Its efficiency depends upon 
its holding firmly upon the fragments, and not permitting them to slide from its 
grasp. All the tendinous insertions into the patella are continuous with the 
anterior margins and surface of the bone ; so that there is no natural sulcus to 
receive the ring, or uplift against which the ring or any similar form of dressing 
can obtain a bearing, unless it is very firmly pressed into the tissues above and 
below, as I have before explained. Such pressure as is required in the case of 
a ring, or any similar hard and unyielding mode of pressure, will not often be 
borne by an inflamed and swollen structure. 

Plaster-of-Paris and all other forms of immovable dressings do not 
possess one single point of excellence or advantage. When first applied 
they are liable to constrict the limb dangerously ; and how insidiously a 
fatal gangrene may progress, giving no sign either by pain or general 
disturbance until the destruction is nearly complete, the case seen by 
Defer, and referred to in the preceding pages, will show. The cases 
which I have reported also in the preceding pages demonstrate how in- 
efficient these dressings are as a means of approximating the fragments ; 
the examples of the widest separation being drawn almost exclusively 
from cases treated by the plaster-of-Paris or the silicates. The dress- 
ings, which within a few days or hours are apt to become very tight in 
consequence of the increased swelling, soon begin to loosen, from the 
subsidence of the swelling at first, and finally from atrophy of the 
muscles and other soft tissues, and the limb lies loose in its case, which 
may not even touch the patella, much less make any effective pressure 
upon it. Whatever the result may be under such circumstances, so far 
as the separation of the fragments is concerned, the dressing has nothing 
to do with it. It may be that the final separation will be found to be 
very little, but, if it is, it would have been the same if the limb had been 
laid horizontally in bed without dressings or apparatus of any kind. 

Some have attempted to remedy this serious objection to these dressings by 
first applying adhesive plaster in the form of a lock strap, and in various other 
ingenious ways, above and below the fragments. I have seen this done repeat- 
edly at Bellevue, and my reported cases furnish quite a number of examples ; 
but, in almost every case, the straps soon became painful and had to be removed, 
and this required the opening of the plaster splint or its entire removal. In one 
of the cases (33) reported by me, the adhesive strips held in place by elastic 
bands caused such excessive pain as demanded the use of hypodermic injections 
of morphine repeatedly, and it resulted in almost complete paralysis of the 
extensor muscles of the foot, which continued many months after the treatment 
was suspended ; yet from all this there was no appreciable gain, inasmuch as 
the fragments united by ligament with the usual amount of separation. Indeed, 
so far as the position of the fragments is concerned, the dressings had only 
proved mischievous by thrusting one of the fragments laterally. Plaster-of- 
Paris is of all the forms of immovable dressings the worst, because it is the 
heaviest; but of them all it must be said that they are unnecessarily cumbrous 
as a form of portative apparatus ; they are to some extent dangerous, especially 
in the hands of inexperienced surgeons ; they are inefficient as means of approxi- 
mating the fragments ; they actually serve but one single purpose, namely, to 
keep the limb straight, and this they do too effectually in many cases, causing 
an unnecessary degree of passive ankylosis. The limb can be maintained in a 
straight position by a much simpler and lighter dressing than a plaster-of-Paris 
splint, and by means which permit it to be daily examined and the condition of 
the fragments noted and corrected. 



454 FRACTURES OF THE PATELLA. 

My own method is as follows : The limb being placed extended, with 
the foot elevated about six or eight inches, a long splint is applied to the 
back of the thigh and leg. This splint may be made of leather, of gum- 
shellac cloth (not felt), or of any other material having the necessary 
qualities of firmness, lightness, and plasticity, so that it can be properly 
moulded to the limb. Of late I have preferred the gum-shellac cloth, as 
possessing in a greater degree the necessary qualities than either of the 
others. The splint should be long enough to extend from above the 
middle of the thigh to two or three inches above the heel. Its width 
should be sufficient to inclose the posterior semi-diameter of the leg and 
thigh. It should be placed in hot water, and then moulded to the back 
of the limb : only that it is rather better not to fit it accurately to the 
popliteal space, in order that a small amount of cotton-batting may be 
placed between the splint and the skin. The splint should then be re- 
moved ; and, if made of shellac-cloth, in a few minutes it will be suffi- 
ciently hard to retain its form. It is now covered completely with a firm 
cotton or woollen sack, and the sack stitched along the back of the splint. 
The splint having been curved to fit the circumference of the limb, the 
sack must hang loose across the concave surface of the splint, so that the 
limb may be allowed to fall back to the splint, but the ends of the sack 
may be drawn and stitched tightly. 

One object of the covering is to furnish a protection to the skin against the 
splint; but the chief object is to supply a basis to which the bandage, which is 
to inclose the limb and splint, may be stitched. 

The splint must be applied while the limb is in the position already 
described, a small wad of cotton-batting having been placed in the ham. 
A roller, made of unglazed cotton-cloth, is then turned around the leg 
and splint to within about three inches of the knee, and another from 
the upper end of the splint over the splint and thigh to within three 
inches of the knee. While an assistant approximates the fragments with 

Fig. 290. 




llhlliilliit 

The Author's mode of dressing. 
(The final turns of the roller, in the front of the knee, are not shown in the woodcut.) 

his fingers, the surgeon makes two or three turns with a third roller 
around the limb and splint, close above the knee; after which the roller 
descends below the knee, and an equal number of circular turns are 
made close below the lower fragment of the patella ; and finally, a suc- 
cession of oblique and circular turns are made above and below the frag- 



TREATMENT OF FRACTURES OF THE PATELLA. 455 

ments, which turns are to approach each other in- front until the whole of 
the patella is covered — the last turns being again circular. The dressing 
now being completed, the rollers are carefully stitched to the cover of 
the splint through its whole length, on both sides ; and the limb is left 
supported in the elevated position by a suspending apparatus, or by some 
other mode which will insure its maintenance in this position. 

The cotton-cloth roller is preferred, especially for the purpose of approxi- 
mating the fragments, because, if unglazed, it yields a little, and adapts itself 
smoothly to the skin, even sinking down a little just above and below the 
patella, thus rendering it less liable to slide over. Reversed turns are omitted 
altogether,, because they cause sharp cords where they are folded, and sometimes 
produce painful constrictions and excoriations. Adhesive strips, recommended 
by me in the first edition of this work, I have long since laid aside. They are 
just as liable to slide, they are apt to cut at their free margins, and they have to 
be raised up from time to time to be tightened, and they cannot be stitched and 
thus permanently secured to the cover of the splint. No pads above and below 
the knee are recommended, because they are apt to become displaced, and if 
they remain in place they no more effectually press the fragments together than 
does the cotton roller. No pad is placed in front of the patella, because the last 
turns of the roller press back the fragments as effectually as a pad. Care must 
be taken when the roller is applied and the fragments are approximated, that 
the loose skin in front of the patella is not pressed between the fragments. No 
lotions must be applied, to saturate the dressings. They render the skin more 
liable to excoriations, and they are in no way useful. 

On the second or third day the swelling of the knee will be found, 
probably, to have subsided somewhat, and the oblique turns of the ban- 
dage from above and below the patella will need to be tightened. This 
will be done by over-stitching, with strong thread, the oblique turns ; 
taking care to do this on both sides and so far back that the doubling of 
the cloth will not be over the sides of the exposed portions of the limb. 
The same thing may be required to be done every day, or every second 
or third dav, for two or four weeks. 



Meanwhile it will generally be found — for the position of the fragments can 
always be felt — that the space between them has not been increased, and in most 
cases that it has sensibly diminished from the day of their first adjustment. 

At the end of about four weeks the apparatus should be removed care- 
fully. It is now observed, generally, that the knee is pretty stiff, and 
that the upper fragment cannot without considerable force be displaced 
in any direction. It is ankylosed, and there is very little danger that 
it will thereafter draw up further, and it is not probable that any appa- 
ratus will make it descend. But as a matter of safety, an assistant should 
now press the upper fragment gently downward, while the surgeon flexes 
the knee very slightly, so as to diminish its stiffness. He ought, in 
doing this, never to cause pain, or to use any degree of force. The splint 
is then to be reapplied in the same manner as before. Daily, thereafter, 
the splint should be removed with the same care, and the limb gently 
flexed. In the meanwhile the patient may go about upon crutches if he 
chooses. In six or eight weeks the bond of union may be considered 
completed, and the patient may be dismissed from the immediate care of 
the surgeon, but not until he has been fully informed of the danger of a 
rupture of the new ligament, and has been provided with the means of 



i 



456 



FRACTURES OF THE PATELLA 



protection as far as possible. He must be taught that for the next three 
or four months this danger is great; and that any sudden flexion of the 
limb may cause it ; and, indeed, that it may be caused by simple mus- 
cular action, when the limb is not flexed. During this period he should 
walk only upon crutches, and the knee-joint should be constantly sup- 
ported, unless he is completely at rest. 

The knee-caps usually furnished for this purpose are wholly unreliable. They 
allow the knee to bend too freely. Indeed, nothing but an inflexible splint can 
insure safety ; and the same splint employed in the treatment, reduced one-half 
in length and secured by straps and buckles, is the best I have yet employed. 

Under no circumstances, in my opinion, is the surgeon justified in 
attempting to overcome the ankylosis by force, either with or without an 
anaesthetic. The chances are more than equal that he would substitute 
a ruptured ligament and an ununited patella for an ankylosed knee. 
I have been informed that this accident actually occurred at one of our 
city hospitals a few years ago, in the presence of a class of students. In 
time, and generally within a year or two, the ankylosis will disappear 
wholly under careful and moderate use of the limb. 

I no longer recommend the wooden inclined plane (Fig. 291) in all cases. 
The principle of its construction is correct, and the results have been satisfactory, 
but it is unnecessarily cumbrous for a majority of recent and primary accidents, 
and I reserve it now only for exceptional cases, such, for example, as those in 
which the separation is very great, or the inflammation and swelling are unusual. 

Fig. 291. 




The author's wooden inclined plane. To be used in only exceptional cases. 



Mr. Hutchinson, of London, has of late omitted to elevate the foot in the 
treatment of this fracture, and he thinks that the fragments are maintained in 
apposition with quite as much ease. 1 I cannot agree with him that nothing is 
ever gained by the elevation of the foot. On the contrary, in the treatment of 
a certain proportion of cases this position will be found essential to the best suc- 
cess, while in others it may be of little consequence whether the foot is elevated 
or not. The dressing and apparatus employed by Wood, of King's College Hos- 
pital, are very similar to my own wooden inclined plane, but the splint is only 
five or six inches wide. Wood has substituted hooks for the notches. 2 






1 Hutchinson, London Hospital Reports, vol. xi. 



Fergusson's Surgery, p. 307. 



FRACTURES OF THE TIBIA 
Fig. 292. 



457 




Wood's apparatus. 

Treatment of a Rupture of the New Ligament. — In all cases the 
patient should, as soon as possible, be subjected to the same plan as for 
original fractures, but with smaller hope of a reunion. The time always 
arrives, according to my experience, both in primary fractures and sec- 
ondary accidents or ruptures of the new ligament, when supporting and 
retentive apparatus is worse than useless. The period is within five 
months after the original accident, and within about the same period after 
the secondary accident. 

Under proper and free use of the limb, aided by friction, electricity, 
etc., the muscles will become developed in size and strength, and through 
their remaining attachments to the sides and front of the leg, below the 
knee, will give to the patient often a very useful limb. 

[Compound and otherwise Complicated Fractures. — In these forms 
of fractures antiseptic wiring of the fragments with thorough antisepsis 
of the wound is the proper treatment.] 



CHAPTER XXXI. 



FEACTUEES OF THE TIBIA. 

Development of the Tibia. — The tibia is formed, usually, from three 
centres of ossification — one for the shaft, and one for either extremity. 
Ossification commences in the shaft at or about the fifth week of foetal 
life. In the upper epiphysis it appears at birth, and unites with the 
shaft at about the twenty-fifth year. Generally it forms the tubercle, 
but occasionally the tubercle has a distinct point of ossification. The 
lower epiphysis commences to ossify during the second year, and unites 
with the shaft at about the twentieth year. The malleolus internus is 
occasionally formed from an independent centre. 

Pathology, Division, etc. — In an analysis of twenty-seven fractures of 
the tibia, not including fractures of the malleoli, six were found to have 
occurred in the upper third, eleven in the middle third, and eight in the 
lower third. Six of the twenty-seven are known to have been transverse, 
or only slightly oblique. It is probable, also, that several of the remainder 



458 



FRACTURES OF THE TIBIA. 



were transverse. In this respect, therefore, fractures of the tibia alone will 
be found to differ materially from fractures of the tibia and fibula ; but it is 
only in accordance with the general observation that indirect blows pro- 
duce almost constantly oblique fractures, and direct blows somewhat more 
frequently transverse. According to Heydenreich, 1 fractures of the upper 
third of the tibia occur most often between the 30th and 50th years of 
life, and he has not found a case recorded in a person under 22 years of 
age. Fractures of the tibia extending into the knee-joint are in most 
cases compound, or otherwise so seriously complicated as to render ampu- 
tation sometimes necessary. 



Fig. 293. 



Fig. 294. 



Fig. 295. 








f ,: : 



Development of the tibia. 
(From Gray.) 



Penetrating fracture in which 
the shaft has produced commi- 
nution of the head. 



V-shaped fracture. 



Etiology of Fractures of the Tibia. — Fractures of the tibia alone are, 
in a large majority of cases, produced by direct blows, such as the kick 
of a horse, or a blow from a stick of wood. It is occasionally broken by 
a fall upon the foot, the force of the impulse being expended before the 
fibula gives away, but usually the fibula breaks at the same moment, or 
immediately after the fracture has taken place in the tibia. 

Heydenreich relates the case of a man whose tibia was broken above the 
tubercle in an attempt to straighten an ankylosed knee. The patient died on 
the eighth day, from a hemorrhage caused by the pressure of the displaced frag- 
ment upon the popliteal artery. Dr. Proudfoot, of New York, has reported an 
example of fracture of the tibia in utero, produced in the sixth month of preg- 
nancy, by violent pressure upon the abdomen. 2 

1 Heydenreich, Frac. Ext. Sup. du Tibia, th. de Paris, 1877, No. 43. 

2 Proudfoot, Boston Med. and Surg. Journ., vol. xxxv. p. 268,1846; from New York 
Journ. Med. 



FKACTURES OF THE TIBIA. 459 

[Fractures of the head of the bone may be complicated by injuries of the 
joint. This may occur by a vertical line of fracture through the head into the 
joint, or the lower fragment may be driven into the upper and produce a separa- 
tion! and comminution of the head. (Fig. 294.) 

Other varieties of fractures have been noticed. A person was thrown violently 
to the ground, while wrestling ; he died of pleuro-pneumonia on the twenty- 
third day, when it was found that the spine and central portion of the head of 
the bone and a part of the left articular surface had been torn from the rest of 
the bone. 1 Prof. Dittel, of Vienna, mentions the case of a man who was kicked 
by another in the calf; blood was effused into the knee-joint; it was punctured, 
after which amputation was performed ; on examination of the limb it was found 
that the anterior crucial ligament had become detached from its lower origin, 
detaching an oval piece of the upper surface of the tibia. These fractures have 
been described as " sprain factures" by Mr. Callender. 2 

A form of fracture of the shaft known as V-shaped (Gosselin) may give rise 
to great difficulties in treatment. (Fig. 295.) The upper fragment is somewhat 
pointed and presents on the inner and subcutaneous aspect, and the lower frag- 
ment has a triangular depression with a prominent point posteriorly. A line of 
fracture usually extends from the lower point of the V around the bone, inward, 
backward, and outward, across its posterior surface toward the lower articular 
facet, where the tibia and fibula articulate ; the fissure then passes horizontally 
inward across the lower articular facet of the tibia to the posterior border of the 
inner malleolus to join the one on the posterior aspect of the bone, thereby cut- 
ting off a triangular fragment of the tibia at its lower extremity. This fracture 
is believed to be produced by a twist of the body when the foot is fixed. It may 
be diagnosed when the joint is found to be involved in the fracture. If it is 
compound the bones should be aseptically wired.] 

Separation of the upper epiphysis of the tibia, and of the lower epiphysis of 
the femur, has been occasioned by pulling at the foot during confinement. 3 
Blasius* relates the case of a boy, 16 years of age, in whom the upper epiphysis 
was separated completely from the shaft by having his foot caught in machinery. 
M. Peuleve 5 has in his possession a similar specimen obtained from a lad 6 years 
of age. The accident had been caused by the leg being caught in the revolving 
wheel of a carriage, and the severity of the injury was such that it became neces- 
sary to amputate. Fischer and Hirschfeld 6 have observed the same lesion in a 
boy 17 years old. Voss has seen a separation of the lower epiphysis in a boy 
14 years old, who in falling had caught his foot between two blocks of wood. 
The upper fragment protruded through the skin. Reduction was effected, but 
subsequently a portion of the epiphysis became necrosed and was removed. He 
finally recovered with a useful joint. 7 

Dr. R. W. Smith has reported a similar case in a boy 16 years of age, and 
which, having occurred six months before, remained unreduced. The lower 
end of the shaft was displaced forward. Richard Quain records one other 
example, in a lad 17 years old, which was easily reduced and maintained in 
position. 8 Powell, 9 of Canada, reported an example of congenital displacement 
of the upper epiphysis of both tibiae in an otherwise healthy girl. Reduction 
was easily effected, but was with difficulty maintained. When about 14 months 
old, however, the epiphyses were kept in place by means of plaster-of-Paris 
splints with which she was permitted to walk about, and a perfect union was 
finally obtained. 

Inasmuch as the tubercle has sometimes a separate point of ossification it may 
occasionally be detached, and the accident will then be distinguished from a 
fracture of the ligamentum patellae, by the presence of a hard and movable body 
and by crepitus. 

1 System, of Surgery, vol. i. 

2 St. Bartholomew's Hospital Reports, vol. vi. p. 51. 3 Madame Lachapelle. 
* Blasius, Foncet, Nouv. Die. de Med. et de Chir., t. 19, p. 513. 

5 Peuleve, Bull. Soc. Anat., 1865. 

6 Berlin, klin. Woch., 1865, ii. 10. (Poinsot, op. cit.) 

7 Voss, New York Journ. Med., Nov. 1865, p. 133. 

8 New York Journ. Med., June, 1868: from British Med. Journ., Aug. 31, 1867. 

9 Powell, Canada Lancet, July 1, 1881. 



460 FRACTURES OF THE TIBIA. 

Prognosis. — No shortening can occur in this fracture unless one or 
both ends of the fibula are displaced, a complication which I have noticed 
in two instances, but in neither case did the shortening exceed one- 
quarter of an inch ; unless, indeed, the fibula bends and remains bent, 
or the comminution and direction of the fracture are such at either end 
as to allow the femur or the astragalus to become impacted. I have 
never recognized either of these conditions. Occasionally the upper 
fragment has been slightly displaced forward. With these exceptions, 
and one other of delayed union which I shall presently mention, this 
bone, in my experience, has been found to unite promptly and without 
any appreciable deformity. Other surgeons have noticed occasionally 
that the upper end of the lower fragment has become displaced toward 
the fibula. Delayed union has been observed pretty frequently in frac- 
tures of the upper third of the tibia. 

Muhlenberg, in his tables comprising 656 examples of delayed and non-union 
of long bones, records 84 of the tibia alone ; of which number 2 were cured by- 
friction, 7 by mechanical appliances, 3 by seton, 11 by resection, and 15 by 
drilling. 1 

If the fracture extends into either the knee- or ankle-joint, the danger 
of ankylosis is imminent, yet experience has shown that it may some- 
times be avoided. When the malleolus is broken off, it generally becomes 
slightly displaced downward, and in this position a complete bony or liga- 
mentous union of the fragments generally takes place. 

Treatment. — The tendency to displacement, in a fracture of the shaft 
of the tibia, is usually so slight, if it exists at all, that simple dressings, 
light splints of leather, felt, or binder's board, with rest in the horizontal 
posture upon a pillow, fulfil nearly all the indications which are present. 

The following cases will illustrate the usual course of these accidents : 
Mrs. W. fell, striking on her right knee, breaking the tibia transversely just 
below the tuberosity. The fall was the result of a misstep on level ground, and 
was attended with only slight bruising of the soft parts. On attempting to rise 
the bone projected very distinctly, and she pushed and pulled it into place with 
her own hands. I dressed the limb by laying it upon a pillow, outside of which 
were placed two broad deal splints, tying the whole snugly together with several 
strips of bandage. At a later period the leg and thigh were laid over a double 
inclined plane. At the end of six weeks all dressings were removed, and the 
fragments were found to have united firmly, and so perfectly that the point of 
fracture could not be traced. 

P. H. , set. 29, was admitted into the hospital with an injury to his left leg, 
which had occurred two days before. A surgeon had examined the limb, and 
thought the femur was broken just above the joint, and applied a roller from the 
toes to the thigh ; and to the thigh were applied lateral splints. I could not 
discover any fracture or displacement, and the dressings were discontinued. 
One month later I detected a slipping sensation, like that produced in a false 
joint, through the upper end of the tibia. It was a transverse fracture through 
the upper end of the tibia, and without displacement. No splints were afterward 
applied, and three months after admission he was dismissed, the motion between 
the fragments having ceased, but the knee still remaining quite stiff. 

The presence of inflammation, with other complications, may occasion- 
ally render the treatment more difficult and the results less satisfactory. 

1 Muhlenberg, Agnew's Surg., op. cit., vol. ii. p. 806. 



FRACTURES OF THE TIBIA. 461 

In case the fracture extends into the knee-joint, it is best to lay the 
limb upon pillows in a nicely-cushioned box, and nearly straight. No 
extension or counter-extension is necessary here any more than in other 
fractures of the tibia alone, nor are lateral splints or rollers necessary or 
proper at first as a general rule ; but especial attention should constantly 
be given to the prevention of inflammation, and of subsequent ankylosis. 

The omission to employ splints in a case of this kind was charged against a 
surgeon in Vermont as evidence of malpractice. I am happy to say, however, 
that, in this particular case, he was sustained by the testimony of the medical 
men and by the verdict of the jury ; but the attempt which the reporter has 
made to defend this as a universal practice in fractures of the leg, or of the tibia 
alone, is unfortunate, and evinces a lack of practical experience. 

Whatever position is adopted, and whatever means of support or reten- 
tion are employed, if bandages or splints are applied tightly or injudi- 
ciously, great suffering and irreparable mischief to the knee-joint may be 
the consequence. 

A man, set. 23, entered the Pennsylvania Hospital, July 18, 1839, with an 
oblique fracture through the head of the tibia. A physician had applied a 
bandage and splint to the leg, and sent him twenty miles to the city, and, on 
examination after his arrival, the whole limb as high as the groin was much 
swollen, red, and excessively painful. The knee-joint was distended and very 
tender. All dressings were immediately removed, and the limb laid in a frac- 
ture-box slightly elevated at the foot ; cool lotions were applied, and the patient 
was freely bled, both from the arm and by the application of leeches. The limb 
was kept in this position about six weeks, and at the end of two or three weeks 
more he was dismissed cured. Dr. Norris, who was the hospital surgeon in 
attendance, has, in his report of the case, very properly taken this occasion to 
warn surgeons of the danger of excessive bandaging and splinting in this kind 
of fracture, as well as in other fractures of the lower extremities. 

Fractures of the malleolus, unaccompanied by any other accident, 
demand only that the limb should be laid upon its outer or fibular side, 
with the foot so supported that it shall incline inward toward the tibia. 
In this simple disposition of the limb we have clone all that can be done 
by any mechanical contrivance toward approaching the lower fragment to 
the shaft from which it has been broken. 

In a case of a transverse fracture just below the tubercle of the tibia, the union 
was delayed many months. I perforated the^bone with Brainard's drill several 
times, and, binding a firm splint upon the back of his thigh and leg, he was laid 
in bed. After the first week I pushed an ordinary shawl-pin between the frag- 
ments, and left it in place three days. This was repeated several times, and at 
the end of a few weeks union was complete. 

[If drilling should not succeed after repeated trials, the better treatment is 
the antiseptic wiring of the fragments. It often happens that something is found 
between the fragments, as muscle or loose bone. After wiring the bones the limb 
should be placed in a wire-gauze splint and lightly covered with a plaster band- 
age.] 



462 



FRACTURES OF THE FIBULA 



CHAPTEE XXXII 



FRACTURES OF THE FIBULA. 



Development of the Fibula. — The fibula is formed from three centres 
of ossification — one for the shaft, and one for each extremity. Bone 
begins to be deposited in the shaft at about the sixth week of foetal life, 



Fig. 296. 



Fig. 298. 



Fig. 297. 




Comparative difference be- 
tween the external malleolus of 
man and the higher mammal; 
A, ape ; M, man. 



Development of 
the fibula. (From 
Gray.) 

in the lower extremity during the second year, 
and in the upper extremity during the fourth 
year. The lower epiphysis unites with the shaft 
about the twentieth year, and the upper about the 
twenty-fifth year. 

[Dr. J. B. Sutton, of London, 1 notices the comparative 
length of the external malleolus in man. If this mal- 
leolus in man is compared with that of mammals, which 
so closely approach him in anatomical characters, it 
will be found to descend much lower. (Fig. 297.) He 



Separation of several 
epiphyses in the lower 
limb. (Pick.) 



1 Amer. Journ. Med. Sci., 1! 



FRACTURES OF THE FIBULA. 463 

states that no one has ever described an example of Pott's fracture in a monkey, 
nor, indeed, in any mammal save man ; he concludes that Pott's fracture is 
peculiar to the human kind, and occurs as a distinct result of the extraordinary 
length of the fibula malleolus, in that it affords excessive leverage when the foot 
is suddenly and violently twisted laterally, the force applied to the distal end 
causing the fibula to snap at some point in its lower fourth.] 

Epiphyseal Separations. — Stimson relates that " in April, 1883, a 
child, about two years old, was run over by a street-car and brought to 
the Presbyterian Hospital. In addition to other wounds, which were 
promptly fatal, there was a lacerated wound on the outer side of the right 
leg exposing the upper end of the fibula and opening the knee-joint. 
The epiphysis of the fibula was completely detached from the shaft and 
from the tibia, and remained attached to the external lateral ligament 
and the tendon of the biceps ; there was also an incomplete fracture of 
the shaft of the fibula three-fourths of an inch below the epiphyseal 
line, and the intermediate portion was denuded of its periosteum, which 
remained attached to the epiphysis." 1 

[Pick illustrates this accident (Fig. 298) by a specimen showing several epi- 
physeal separations in the same subject.] 

Causes of Fracture. — In a record of forty-eight cases I have been able 
to ascertain the cause satisfactorily in thirty-two, of which number six 
were the results of falls directly upon the bottom of the foot, but which 
were probably accompanied by a twist of the foot, eleven of a slip of the 
foot in walking on level ground or on ground only slightly irregular, and 
fifteen of direct blows. 

I shall here take the liberty of quoting the careful studies and observations of 
Poinsot: 

"Muscular contraction is sometimes the cause of fracture of the fibula. In 
this case, the superior extremity detaches itself from the rest of the bone. This 
variety of fracture, very rare however, was noted as early as 1854, by Professor 
Hergott, of Strasburg; 2 at the same time, two practitioners of the upper Rhine, 
Weber and Miiller, reported each an observation of the same kind. Brand, in 
1877, reported a case of fracture of the head of the fibula which complicated a 
dislocation of the leg forward. 3 Similar facts were recently published by Messrs. 
Duplay, Perrin, and Terrier. 4 Hergott's patient, a woman fifty-two years old, 
fell; throwing herself quickly backward, she felt a crack in her left leg on which 
her body was resting. A slight tumefaction was discovered opposite the head of 
the fibula, as also a manifest crepitus, felt by the patient as well as by the doctor. 
The fracture in Weber's patient, and probably also in Terrier's, was produced 
in the same way. In Miiller's case, two young men were wrestling ; one of them, 
on the point of being thrown, made a violent effort; but cried out so that his 
adversary let go ; he did not fall, although he could not use his leg. Miiller 
recognized a fracture of the head of the fibula. Brand's patient was knocked 
down backward by a cow on a pile of stones and wood. The leg, in M. Perrin's 
case, was caught between the ground and a fallen horse. M. Duplay's patients, 
men of forty-eight and sixty years, had been caught, one by the shaft of a 
machine, the other by a transmission belt, and their bodies, drawn in a rapid 
movement, struck a neighboring wall repeatedly. The patients explained per- 
fectly, that in the movements of rotation to which they had been subjected, their 

1 Stimson, op. eit., p. 586. 

2 Hergott, Gaz. Med. de Strasburg, 1854, p. 344. 

3 Brand, Bayr. 'artzliches Intell., 1877, No. 52, p. 543. 

4 Bull. Soc. de Chir., 1880, p. 218. 



464 



FRACTURES OF THE FIBULA, 



legs came in contact with the ceiling, so that the inferior right limb (where the 
arrachement of the fibula existed) was struck from outward inward, and conse- 
quently tended to bend violently inward. It seems to us that the mechanism 
admitted by Hergott can be applied to all the cases : the leg being slightly bent 
on the thigh, the biceps contracts with all its strength perpendicularly to the 
line of the fibula, which breaks at its feeblest point. This mechanism, which 
cannot be contested in Hergott's, Weber's, and Miiller's cases, is equally admis- 
sible in Perrin's and Duplay's. One can well understand, that the upper part of 
the leg being fixed in slight flexion by contact with the ground or the ceiling, 
the biceps should act with more efficacy. As to Brand's case, it furnishes no 
details in reference to the mechanism of the lesion ; it seems, however, that Her- 
gott's theory may well be applied to it." 1 

Pathology of the True Fractures. — In all of the fractures recorded by 
me which have been produced by falls upon the bottom of the foot, and 
in all except one produced by a slip of the foot, the accident was accom- 
panied by a partial dislocation of the ankle, the foot being turned out- 
ward. In the one exceptional case mentioned, the dislocation may also 
have occurred, but the fact is not known. In at least ten of the fifteen 
fractures produced by direct blows, the tibia has been thrown more or 
less inward, and consequently the foot has turned out. Occasionally the 
tibia slides a little forward upon the astragalus. But this seldom happens 
as the primary accident ; it occurs later, perhaps within the first ten 
days after the accident, when the heel has been insufficiently supported. 

In thirty-seven examples the fracture of the fibula has taken place within 
from two to five inches of the lower end of the bone. Three times the external 
malleolus was broken off, and eight times the internal malleolus. Five of the 
fractures occurring in consequence of direct blows were compound, and one was 
also comminuted. 

The most frequent form of fracture of the fibula is that first described by 
Pott as follows : " This is the case when, by leaping or jumping,. the fibula 



Fig. 2{ 



Fig. 300. 




Pott's fracture. 




Lines in Pott's fracture. 



breaks in the weak part already mentioned ; that is, within two or three 
inches of its lower extremity. When this happens the inferior fractured 

1 Poinsot, op. cit., p. 652. See, also, Lesions du Sciat. poplit. ext. dans frac. de l'ext. sup. 
du Perone. Duplay, Prog. Med., Paris, 1880, viii. 257. 



FKACTUKES OF THE FIBULA 



465 



end of the fibula falls inward toward the tibia, that extremity of the 
bone which forms the outer ankle is turned somewhat outward and up- 
ward, and the tibia, having lost its proper support, and not being of itself 
capable of steadily preserving its true perpendicular bearing, is forced off 
from the astragalus inward, by which means the weak bursal or common 
ligament of the joint is violently stretched, if not torn, and the strong 
ones, which fasten the tibia to the astragalus and os calcis, are always 
lacerated ; thus producing at the same time a perfect fracture and a 
partial dislocation, to which is sometimes added a wound in the integu- 
ments made by the bone at the inner ankle." 1 

Maisonneuve 2 thinks he has established, by experiments upon the cadaver, 
that the fracture of the fibula at its lower extremity is caused not by forced 
abduction of the foot, but by violent outward rotation ; while M. Tillaux, 3 by 
the same mode of experimentation, has reached a different conclusion. Accord- 
ing to M. Tillaux, the first effect of the forced abduction is to tear the internal 
lateral ligament, or to fracture the internal malleolus. The force, continuing to 

Fig. 301. 




Mechanism of -fracture of the lower end of fibula; A, parts in normal position; a, tibio- 
fibular ligaments; b, external lateral ligaments; a, internal lateral ligaments. B, fracture 
of fibula clue to eversion of the foot. C, fracture of the fibula due to inversion of the foot. 

(Treves.) . 

operate in the same direction, presses the astragalus against the external malle- 
olus and tends to separate the fibula from the tibia, and may so far rupture the 
inferior peroneotibial ligament as to cause a diastasis of the articulation ; or a 
portion of the lower eud of the tibia upon which the ligament is attached may 
be torn off; or, the diastasis not having taken place, the fibula may break above 
the peroneo-tibial ligament. To this fracture M. Tillaux gives the name " bi- 



i 



1 The Chirurgical Works of Percival Pott, F.E.S., Surgeon to St. Bartholomew's Hospital. 
First Amer. ed., 1819, p. 248. 

2 Maisonneuve, Arch. Gen. de Med., fev. et avril, 1840. 

3 Tillaux, Anat. Top., Paris, 1877, pp. 1172-1175. 

30 



466 FKACTUKES OF THE FIBULA. 

malleolar by abduction." It is essentially the typical Pott's fracture, although 
it was not so described in all points by him. In the forced movement of adduc- 
tion, on the other hand, the external lateral ligament is first put upon the stretch, 
perhaps ruptured, or the external malleolus is torn off, sometimes at its summit, 
but most often at its base. In this case the fragment is not usually displaced, 
nor is the foot in any way deformed. It is a fracture by arrachement alone, and 
is not complicated with any other fracture. But the astragalus released by the 
rupture of the external lateral ligament, or of the malleolus externus, and con- 
tinuing to press inward upon the malleolus interims, finally causes a fracture of 
this latter also, at its base. This he calls the " bi-malleolar fracture by adduc- 
tion." It may happen, also, that neither the external lateral ligament nor the 
malleolus externus having given way, the fibula will break above the inferior 
peroneo-tibial ligament, and, the force continuing to act, the lower end of the 
body of the tibia will be torn off in whole or in part. This he terms a " trans- 
verse supra-malleolar fracture." 

These observations made by Tillaux, like all similar observations made ex- 
clusively upon the cadaver, must be accepted, as applied to the living subject, 
with some degree of reserve, since they lack the conditions of rigidity of the 
muscles, with force and direction of impact, which in a degree more or less con- 
tribute to the peculiar lesions in the latter. 

• Prognosis. — Says Poinsot : l u The prognosis of fracture of the fibula 
(at its upper end) by arrachement is grave ; this is not due so much to 
the bony lesion as to the consequent wounding of the external popliteal 
branch of the sciatic nerve. This wound is noted in all the observations 
mentioned by me. In the case of Hergott's patient, flexion made the 
primary pain cease, but for two months and a half walking was impos- 
sible. Weber's patient experienced a permanent incomplete paralysis of 
the flexors of the foot ; in Muller's case, the calf remained painful for a 
long time. In Brand's case, there persisted for some time an incomplete 
paralysis of the muscles and a local anaesthesia of the integument, in the 
treatment of which the inducted currents had to be resorted to. In the 
two patients observed by M. Duplay, the one who survived exhibited, 
after the lapse of a year, a complete paralysis of the extensors of the 
foot and of the lateral peroneal mucles ; he could hardly take a few steps 
with crutches. In M. Perrin's patient, after a period of two months, the 
paralysis remained the same as on the first day. Finally, M. Terrier 
noticed in his patient violent pains in the dorsum of the foot with anaes- 
thesia, from the beginning ; but before long, these primary phenomena 
were succeeded by secondary accidents producing pain. The relations 
of the external peroneal nerve with the head of the fibula, the contour 
of which it follows before lodging into the interosseous space, explain the 
reason why it is frequently wounded under those conditions. Being torn 
by the bone at the time of the accident, that nerve may afterward be 
included in the effusion which, later on, will constitute the callus." 

In a majority of cases, where the fibula has been broken from two to 
five inches above the lower end, the fragments have united inclined 
toward or resting against the tibia ; occasionally I have seen them dis- 
placed backward or forward. Once the fibula refused to unite altogether. 
The malleoli have generally united nearly or quite in place, but in two 
instances the external malleolus has been found displaced very much 
downward. 

1 Poinsot, op. cit., p. 655. 



FRACTURES OF THE FIBULA. 467 

Of the compound fractures, two required amputation, one was treated by- 
resection of the lower end of the tibia, and two died without any operation. 
Douglas has reported a case of compound dislocation with fracture of the fibula, 
which being reduced he was able to save the limb, but not without much diffi- 
culty, and the ankle remained stiff. 1 

Of those which recovered, forty-six in number, twelve were found to 
have more or less unnatural prominence of the internal malleolus, and 
in two of these the malleolus, or lower end of the tibia, projects very 
much. In nearly all of these latter examples the foot appears somewhat 
inclined outward. Generally the ankle-joint has remained stiff for some 
time after the bandages have been removed ; and probably in all cases in 
which the accident was accompanied by a dislocation of the tibia. But 
this stiffness has usually disappeared after a few weeks or months. 

Twice I have noticed considerable stiffness after about six months ; three times 
after one year ; in one case after two years ; and in one case after twenty years 
the ankle would occasionally swell, and become quite stiff. In one case it 
remained almost immovable after twenty years ; and in a still more remarkable 
instance, I examined the limb thirty years after the accident, when the man 
was sixty-three years old, and although there existed no swelling or deformity, 
yet this leg was not as muscular as the other, and he declared that up to that time 
the ankle remained quite tender to the touch, and that occasionally it became 
painful. 

When I come to speak of dislocation of the ankle, I shall adopt the usual 
nomenclature, and shall name all those dislocations in which the tibia projects 
inward from the foot, " inward dislocations of the tibia ;" yet I have some doubts 
as to the propriety of calling this a dislocation, either partial or complete. This 
accident seems to me to have been in general rather a lateral rotation of the foot, 
or of the astragalus, upon the lower articulating surfaces of the tibia and fibula. 
Of all the ginglymoid joints, the ankle approaches most nearly in form to a ball- 
and-socket joint, in consequence especially of the marked prolongations of the 
malleolus internus and externus. In other ginglymoid articulations lateral dis- 
placements are not infrequent, but lateral rotation can scarcely by any accident 
occur. Here, however, the reverse holds true; lateral displacement is difficult, 
while lateral rotation is comparatively easy of accomplishment. 

The majority of cases which occur, involving a disturbance of the rela- 
tive position of the ankle-joint surfaces, are lateral rotations within the 
capsule rather than true dislocations ; and although the restoration of 
the joint surfaces to position is, in general, easily accomplished, yet in 
consequence of either a fracture of the fibula or malleolus internus, or of 
a rupture of the internal lateral ligaments, it will generally happen that 
some deformity will remain. The fragments of the fibula will fall inward 
toward the tibia, and the foot, unsupported by either its fibula or its 
internal ligaments, will incline perceptibly outward. Nor can this be 
wholly prevented, in most cases, by any mechanical contrivance. 

Indeed, it would be easy to demonstrate that even Dupuytren's splint, here- 
tofore so much employed in this accident, must fail of success in a great majority 
of cases; since the subsequent deformity is due less to the fracture of the fibula 
and its consequent displacement than to the loss of the internal ligaments, which 
I03S nature can seldom fully repair. As further evidence of the correctness 
of this view, I will state that in three of the examples in which I found the 
fractured fibula united and resting against the tibia, the motions of the ankle- 
joint have been completely recovered. 

1 Boston Med. and Surg. Journ., vol. xxxiv. p. 336, from Southern Journ. of Med. 



468 



FRACTURES OF THE FIBULA 



I do not here refer to those cases in which a portion of the outer and 
lower extremity of the tibia being also broken off obliquely, and more or 
less displaced, perhaps rotated upon its axis, the perfect approximation 
of the tibio-peroneal articulation becomes impossible. Such cases neces- 
sarily entail serious deformity. If, however, it were true that a fracture 
and displacement of the fibula is the sole or essential cause of the subse- 
quent deformity, it would still be found often impracticable to avoid the 
maiming, since it would still remain impossible to lift the broken ends from 
the tibia, against which, or in the direction toward which, they are so prone 
to fall. Inversion of the foot does not accomplish it, nor have I ever been 
able to make anything but the most trivial impression upon the upper end 
of the lower fragment by pressure upon the lower extremity of the fibula. 

Treatment. — Too much confidence has been placed in the efficiency of 
" Dupuytren's splint." I believe, indeed, that this splint is, in many" 
cases, a very appropriate means of support and retention after this acci- 
dent ; but I doubt whether it is able to accomplish all that its illustrious 
inventor proposed, and especially in those cases in which, the fibula being 
broken, and the internal lateral ligaments torn, the astragalus is disposed 
to glide backward ; of which I have seen several examples, some of 
which have left a permanent and serious deformity, in the elongation of 
the heel and shortening of the foot in front of the tibia. It does not 
appear that either Pott or Dupuytren was aware of this 
Fig. 302. form of displacement from this cause : 

Dupuytren's mode of dressing is essentially as follows : 
A pad, or long junk, made of a piece of cotton-cloth, stuffed 
with cotton-batting, is constructed of sufficient length to extend 
from the condyles of the femur to a point just above the malle- 
olus interims. This pad must be about rive or six inches in 
width, and thicker by two or three inches at its lower than its 
upper end. This is to be laid upon the inside of the leg, with 
its base or thickest portion resting against the tibia just above 
the internal malleolus. Over this pad is to be placed a long 
firm splint, extending also from above the knee to three inches 
beyond the bottom of the foot. With a few turns of a roller the 
upper end of the splint must now be made fast to the knee, and 
with a second roller the lower end secured to the foot. The 
application of this last bandage requires, however, some care in 
its adjustment. Its purpose is simply to rotate the foot inward, 
while at the same time the tibia is pressed outward ; and to this 
end it must be applied in the form of a figure-of-8 over both 
splint and foot, embracing alternately the heel and the instep. 
In order to be effectual, it must be drawn pretty firmly, and 
no portion of the bandage must pass higher than the malleolus 
externus. In some surgical books I have seen this apparatus 
represented with a roller embracing the whole length of the leg ; 
and in others it is represented as encircling the limb two or 

three inches above the malleolus (Fig. 302) ; but it is evident that these modes 

of dressing must defeat the great object which Dupuytren had in view, namely, 

the throwing out of the upper end of the lower fragment. 

When the limb is thus dressed, the knee may be flexed and the leg laid upon 

its outside, supported by a pillow, or upon its inside, as in the accompanying 

engraving (Fig. 303). 

If it is only a fracture of the external malleolus, or if the fracture has 
occurred in the middle or upper third of the bone, this treatment is no 




Dupuytren's 
splint, incor- 
rectly applied. 



FRACTURES OF THE FIBULA 



469 



longer appropriate, and it will generally be found sufficient to place the 
limb at rest for a few days upon a suitable cushion or upon a pillow. 



Fig. 303. 




Dupuytren's splint as originally applied by himself. 



Fig. 304. 



Of late years I have not employed Dupuytren's splint, and especially 
because I have met with several examples of backward displacement of 
the foot following fractures of the fibula, which Dupuytren's splint is not 
competent to prevent or to remedy. This accident can be most certainly 
avoided by employing the plaster- of-Paris or starch dressing; taking care 
in applying the dressing to secure a thorough inversion of the toes and 
foot, the same as in case the limb were dressed with Dupuytren's splint. 
Care must be taken, also, not to permit the bandages to press upon the 
limb above the malleolus externus. The same 
results may be attained by well-adjusted leather, 
felt, shellac, or gutta-percha splints, which inclose 
the heel as well as the sides and front of the 
limb. 

[It is of the utmost importance to overcome com- 
pletely the displacement outward while the dressing is 
being applied, and to maintain it until the plaster is 
hard. The inversion of the toes is useless unless the 
tarsus is restored from its outward luxation. To effect 
this, pressure must be made upon the outside of the 
foot below the malleolus, and counter-pressure upon 
the tibia above the joint.] 

It is scarcely necessary to say that, since after 
the accident ankylosis is so frequent, early and 
unremitting attention should be given to the 
establishment of passive motion in the joint. 
Indeed, I cannot but think that a desire to 
accomplish the indications recognized and urged 
by Dupuytren has led to the neglect of the indi- 
cation which ought to have been regarded as of 
equal, if not of the greatest, importance, namely, 
the prevention of contractions and adhesions 
around and between the joint-surfaces. I can- 
not too often call the attention of the suro-eon 

bandages, to which I have frequently made reference elsewhere ; and 
especially does it seem necessary here because I have recommended the 
use of the plaster-of-Paris bandage in this form of fracture, from which 
the greatest dangers are always to be apprehended, unless it is used 




Badly-set Pott's fracture, 
curable by operation. 
(Ericbsen.) 

to the danger of tight 



470 FKACTURES OF THE TIBIA AND FIBULA. 

carefully and skilfully. As a general rule, the dressings ought to be 
wholly laid aside by the end of the third or fourth week ; and although 
it may be well for a somewhat longer time to keep the foot turned in, by 
having it properly supported as it lies upon the pillow, yet after this 
date I regard the use of splints and bandages as only pernicious. 

[Correcting Deformity. — In badly-set Pott's fractures Mr. Erichsen has 
divided the fibula subcutaneously, with a narrow-bladed saw, at the point of 
greatest curvature, and then forcibly adducted the foot. Dupuytren's splint 
was then applied. 

Le Dentu employed an osteoclast, which made pressure at three points, viz., 
two on the outside, one on the leg and the other on the instep and malleolus, 
and the third on the inside of the tibia just above the malleolus. On refracture 
the limb was placed in proper position, and a plaster dressing applied. 

Fenger, of Chicago, performed osteotomy in a similar case. The operation 
consisted in cutting from the tibia a wedge-shaped piece, having the base, one 
inch thick, on the inner side, and the apex on the outer surface ; the fibula was 
next broken, or drilled and broken. The foot was then brought into position. 

Sabine, of New York, divided each bone with a chisel subcutaneously, about 
an inch above the malleoli, and obtained good results.] 



CHAPTEK XXXIII. 

FRACTURES OF THE TIBIA AND FIBULA. 

Causes. — A majority of these fractures are the results of direct blows 
or of crushing accidents, such as the kick of a horse, the passage of a 
loaded vehicle across the limb, the fall of heavy stones or timber, etc. 

In an analysis of 217 cases, where I could ascertain the cause, I have found 
the bones broken in the upper third from a direct cause 7 times, and from an 
indirect cause 3 times. In the middle third 52 have been referred to a direct 
cause, and 10 to an indirect ; and in the lower third 50 to a direct cause, and 
32 to an indirect. An observation which does not sustain the remark of 
Malgaigne, based upon his analysis of cases, that fractures of the upper third 
are produced by direct causes alone, those of the middle third much more fre- 
quently by indirect causes, and that those of the lower third are especially due 
to indirect causes. 

Of the indirect causes, falls upon the feet from a considerable height — 
as from a scaifolding, or from a top of a building — are by far the most 
common. Eight times I have found the bones broken by muscular action 
alone. 

Pathological Anatomy. — We have seen that fractures of both bones 
through some part of the lower third are most frequent. Thus, of 2 1 7 frac- 
tures, 22 belonged to the upper third, 7 to the middle, and 125 to the lower. 
In some cases the two bones were broken in different divisions. It is often 



FRACTURES OF THE TIBIA AND FIBULA. 



471 



difficult, and sometimes quite impossible, to determine precisely where 

the fibula is broken ; but the analysis is sufficiently correct to illustrate 

the much greater frequency of fractures of the lower 

third, and also the fact that the two bones generally FlG - 305 - 

break nearly on the same level ; usually the point of 

fracture in the tibia is between two and three inches 

above the joint. 

In an examination of twenty museum specimens, I have 
found both bones broken at the same point, or within two 
or three inches of the same point, sixteen times, and at 
extreme points four times ; and in these last examples the 
tibia has always been broken in the lower third, while the 
fibula has been broken in the upper third. In twenty of 
the fractures mentioned as belonging to the lower third 
only the malleolus of the tibia was broken, while the fibula 
was broken two or three inches above its lower end. Some 
of these were complicated with dislocation of the angle. 
I have seldom seen a transverse fracture of the tibia, ex- 
cept in its lower or upper extremity, in the expanded por- 
tions of the bone ; and even in those examples which we 
are accustomed to call transverse, because they are suffi- 
ciently so to prevent any sliding or overlapping of the 

fragments, there has existed, generally, a marked inclination of the line of frac 
ture in one direction or another. 




Fracture of tibia and 
fibula. 



The examples of fracture produced by muscular action have, without 
an exception, occurred in adults. Five of them were in the lower third 
of the leg, and three in the middle third. I think they were all of them 
nearly transverse, since they never became much, if at all, displaced. 
Most of the fractures of the tibia produced by falls upon the feet are very 
oblique, and the direction of the fracture is generally downward, forward, 
and inward ; but I have found almost every conceivable variation from 
this general rule. The fracture in the fibula is even more constantly 
oblique than the fracture in the tibia ; but this is a point of very little 

Fig. 306. 




Compound and comminuted fracture of tbe leg. 



practical consequence, and one which we can seldom determine positively, 
unless one of the fractured ends protrudes through the flesh. Compound 
and comminuted fractures are more frequent here than in any other^of 
the bones of the body. 



472 FRACTURES OF THE TIBIA AND FIBULA. 

Of 217 fractures, 74 were compound, aud also, frequently, more or less com- 
minuted. Of 80 cases reported by W. W. Morland, of Boston, from the Massa- 
chusetts General Hospital, in which the character of the accident is recorded, 
39 were compound. 

Symptoms. — The symptoms indicating a fracture of both bones of the 
leg are the same which are usually present in other fractures, namely, 
mobility, crepitus, shortening of the limb, distortion, swelling, etc. Gen- 
erally, the lower end of the upper fragment projects in front, and can be 
seen or felt ; but in some instances the swelling follows so rapidly that it 
is impossible to feel distinctly the point of fracture, and its existence can 
only be determined by the crepitus, mobility, and shortening of the limb, 
or, perhaps, by the marked deformity or deviation from the natural axis. 
The shortening, where it exists at all, varies at the first from a line or 
two to one inch. Generally, it is about half an inch. 

Prognosis. — The average period of perfect union in twenty-nine cases, 
including those in which union was delayed by extraordinary causes 
beyond the usual time, was forty days. The general average, under 
ordinary circumstances, may be stated at about thirty days. Union has 
been noted as delayed a few weeks beyond the usual time in at least 
twelve cases of simple fracture. Cases of complete non-union are less 
frequent here than in the femur or humerus, the union taking place 
spontaneously often after the lapse of several months. In most oblique 
fractures of the shafts of these bones, union takes place with some short- 
ening, the average being, even in simple fractures, about half an inch, 
but in some cases I have found the shortening one or even two inches. 
With judicious management, however, in simple fractures, this amount 
of shortening seldom or never occurs. 

Generally, when a shortening has occurred, I have found the upper 
fragment in front of the lower, and oftener a little more upon the inner 
than upon the outer side. A deviation from the natural axis of the limb 
has been noticed by me in a good many instances. Several times the 
lower part of the limb has fallen backward ; or, in consequence of its 
having rested too much upon the heel, it has inclined forward ; and in 
other cases it has inclined inward or outward. Ulcers upon the back of 
the heel, seen by me many times, as a result of undue pressure upon this 
part, have, however, been presented but seldom in cases of simple frac- 
tures. It is not very unusual to find, also, over the exact point of frac- 
ture, and after the lapse of several months, or even years, an ulcer, or 
sinus, which is due sometimes to the presence of a small fragment of bone 
which has remained in the wound from the time of the accident, or to a 
thin scale which has subsequently exfoliated. In other cases it is due 
to the prominence of the salient angle when the lower part of the limb 
inclines considerably backward ; and in still other cases, no doubt, to the 
general dyscrasy of the system, and to the same causes which produce 
chronic ulcers in the lower extremities where only the skin has been 
originally injured. 

A boy, four years old, received an injury, breaking both bones of one of his 
legs near its middle. The fracture was compound. Twenty-three years after 
the accident he called upon me on account of a paralysis of his lower extremities 
which had recently occurred. He stated that from the time of the fracture until 



FRACTURES OF THE TIBIA AND FIBULA. 473 

within about one year an open ulcer had existed over the seat of fracture, and 
that soon after it had closed over completely he began to lose the use of his 
limbs. During the time it was open, small scales of bone have frequently been 
thrown off. The limb is half an inch shorter than the other, but straight. 

A gentleman had his tibia and fibula broken near the ankle-joint by the pas- 
sage of a carriage- wheel across his limb. The skin was a good deal lacerated. 
The wounds, however, healed kindly, and the broken bones united in the usual 
time without any apparent deformity; but the limb continued swollen and 
painful, until finally suppuration took place. After twelve years of great suffer- 
ing, I amputated the leg near its middle, from which time he made a speedy 
recovery. I found the lower end of the tibia inflamed, softened, and expanded, 
and containing in its interior about three ounces of pus, but no sequestrum. 

Ankylosis of the knee- or ankle-joint may follow as a result of the 
accident or of improper treatment ; and at one or both of these joints I 
have found more or less ankylosis at the end of nine months, one year, 
six years,* twenty-five, thirty, and forty years. Generally, however, it 
disappears in a few weeks, and seldom remains to any considerable ex- 
tent in the knee-joint after the dressings have been removed two or three 
weeks. 

In Muhlenberg's tables, already referred to in previous chapters, there are 
recorded 94 cases of delayed union or of non-union of these two bones at the 
same time; also 84 similar cases in which the tibia alone was ununited, and 2 
in which the fibula alone was ununited : making a total of 180 cases. 

After all that has been said as to the occasionally serious nature of 
the consequences of these accidents, as shown in the shortening of the 
limbs, in their deviations from their natural axes, in the stiff ankles, 
ulcers, and abscesses, it must be still admitted that in another point of 
view these results are not extraordinary, and may hereafter continue to 
be fairly anticipated in a certain proportion of cases, even under the best 
management ; since it must be understood that more fractures of the leg 
are attended with serious complications than of any other limb ; and that 
while many produce death rapidly from the severity of the shock, and 
very many are condemned at once to amputation, a large number of 
those which are saved have been in that condition which has rendered 
the application of bandages or splints impossible for many days. Indeed, 
not a few of these crooked limbs may still be presented as real triumphs 
of the art of surgery, inasmuch as by consummate skill alone have they 
been saved. 

Treatment. — It is wholly impossible in a class of fractures which 
present so great a variety in regard to form, seat, and complications, to 
establish any universal system of practice ; nevertheless, it is possible to 
declare certain general principles in reference to a few well-recognized 
classes or varieties : and I shall deem it especially important to record 
my disapproval of certain plans of treatment which have from time to 
time been suggested and adopted. 

It is seldom that I have found it necessary or useful to apply any 
bandages directly to the skin, whatever form of apparatus has been em- 
ployed ; but in certain cases of compound fractures, where primary dress- 
ings have been applied which needed support and protection, a bandage 
has been of service. The roller, unless the patient is a child, whose limb 
can be easily lifted and managed, is always objectionable ; but the many- 



474 



FRACTURES OF THE TIBIA AND FIBULA. 



tailed bandage, made of narrow strips of cloth, laid upon each other, as 
we have already described in our general remarks upon bandages, etc., 
is occasionally useful. 

Having made these preliminary dressings, we flex the leg to a right 
angle with the thigh, and by the hands make extension and counter- 
extension as much as the patient will bear, or as much as may be neces- 
sary to restore the fragments to place, in case this restoration is found 
to be practicable. If the fracture is compound, and the point of bone 
protrudes through the skin, it is often difficult to replace it. That is, 
we are unable to overcome the action of the muscles sufficiently to make 
the limb of its natural length, and for this reason, mainly, we are unable 
to get the point of bone beneath the skin. If we cannot then " set " the 
bone, or bring the ends into apposition, and this will be the fact pretty 
often, we still have no apology generally for leaving the bone, outside of 
the skin. First, an attempt must be made to accomplish this reduction 
by pulling aside the skin with the fingers, or with a blunt hook. This 

Fig. 307. 




Method of reducing a compound fracture. 



simple procedure has often succeeded with me in a moment, when others 
have been trying in vain to accomplish the same end by pulling upon the 
limb. If this fails, then the skin should be cut sufficiently to allow the 
bone to retire, or if the point is sharp, and especially if it is stripped of 
its periosteum, it may be sawn or cut off. Resecting thus the end of an 
oblique fragment does not generally affect in any degree the length of the 
limb, or interfere with a prompt and perfect cure, but, on the contrary, 
it often is advantageous in every point of view. In certain exceptional 
cases we may find it advantageous to employ an anaesthetic to aid us in 
the reduction. 

Before, however, considering the character and form of the splints to 
be applied, it seems proper to call attention again to the danger of liga- 
tion of the limb from the tightness of the bandages, and especially from 
the use of a bandage or roller placed beneath the splints and directly 
against the skin. The large size and irregular form of the bones of the 
leg, the small amount of muscular tissue covering them, especially near 
the articulations, the severity of the injuries to which they are liable, 
with their remoteness from the centre of circulation — these circumstances 
altogether, render them exceedingly exposed to injury from the too great 



FRACTURES OF THE TIBIA AND FIBULA. 475 

or unequal pressure of splints or of bandages ; and it has often occurred 
to myself to find the skin vesicated, or even ulcerated and sloughing, 
■when the patients are first admitted to the hospital ; a condition which, 
in nine cases out of ten, is due to the maladjustment of the splints or to 
the tightness of the bandages. If bandages are used under the splints, 
and next to the skin, they must be applied very moderately tight, and 
loosened or cut as the swelling augments; and, from the first day of 
treatment to the last, the surgeon must be careful to loosen or tighten 
the dressings when the swelling increases or subsides. 

Dr. Krackowizer presented to the New York Pathological Society, June 10, 
1863, a leg which he had amputated for gangrene occasioned by tight bandages. 
A boy, five years old, sustained an injury of the ankle-joint, which his medical 
attendant pronounced a fracture of the fibula, and for which he applied only a 
tight bandage. The child suffered a good deal after the bandage was applied, 
and the following morning the toes were blue, but the doctor paid no attention 
to this circumstance. The pain subsided on the third day, and on the fourth 
the bandages were removed, and the limb found to be gangrenous. The speci- 
men showed that the fibula was not broken, but that there was a fissure or crack 
in the lower part of the shaft of the tibia. 1 

The following case has been communicated to me by Dr. Fuller, of Wyoming, 
N. Y. A man, set. 71, fell from a tree, striking upon his foot, producing a 
backward dislocation of both the tibia and fibula upon the astragalus, and also 
a fracture of both bones of the leg a few inches above the ankle. An empiric 
immediately applied lateral splints and a firm roller from the toes to the 
knee. Notwithstanding the remonstrances and prayers of the patient to have 
the bandage loosened, it was kept on until the ninth day, when the doctor cut 
the bandage upon the top of the foot, and it was found vesicated. Ignorant, 
however, as to the cause of this vesication, and of the danger which it threat- 
ened, he omitted to loosen the remainder of the bandages, and the limb was left 
in this condition until the twenty-third day, when Dr. Fuller removed all the 
dressings, found the integuments covering the whole foot dead and dried down 
to the bones. The dislocation had not been reduced. Soon after this the limb 
became cedematous, and on the 27th of October the leg was amputated, from 
which time the patient recovered rapidly. 

The fragments being adjusted, two lateral splints of leather, long 
enough to extend from near the knee-joint to the metatarso-phalangeal 
articulations, and wide enough nearly to encircle the limb, are moulded 
to the limb on each side, and secured in place by successive turns of the 
roller. When the skin is delicate or tender, these should be underlaid 
with a thin sheet of cotton wadding or of sheet lint. A soft woollen 
cloth may answer the purpose equally well. A rack is then placed over 
the limb, such as will be seen figured for the suspension of the limb when 
dressed with plaster-of-Paris, and from this the leg is suspended. The 
objects to be obtained by the suspension are threefold : first, to avoid the 
danger of pressure upon the heel, and consequent ulceration ; second, to 
prevent that driving down of the upper fragment upon the lower which 
constantly ensues when the foot rests upon the bed, or in a box which is 
immovable; third, to obviate movement of the fragments upon each other 
when the patient sits up or lies down in bed. This movement, I observe, 
is peculiar. It is not simply a motion of the fragments upon each other, 
as upon a pivot at the point of fracture, which motion seldom interferes 

1 Krackowizer, Amer, Med. Times, Nov. 7, 1863. 



476 FRACTURES OF THE TIBIA AND FIBULA. 

materially with consolidation, but it is a rising and falling of the upper 
fragment, or a motion to and fro of the fragments, and also a riding 
motion ; either of which latter movements necessarily delays or defeats 
bony union. It is because these motions are generally permitted to occur 
in the usual modes of dressing these fractures, more than for any other 
reasons, that union is so often delayed in the case of these bones. In 
my own practice, when this plan of suspension is enforced, delay seldom 
occurs ; but nothing is more common than for me to meet with it when 
other surgeons have had charge of the limb, and the suspension has been 
omitted. In suspending the limb, it is only necessary that the leg should 
float clear of the bed; and I think it worth while to say that when lateral 
splints only are used, broad oval pieces of leather or of some other firm 
material should receive the limb in suspension, rather than narrow pieces 
of bandage, which soon become cords, and press unequally. To the 
sides of these oval pieces bands are attached, and their ends tied over the 
top of the rack. One must be placed under the knee and one under the 
ankle. If the fracture is above the middle of the leg, complete quietude 
of the fragments can only be obtained by carrying the splints and the 
bandages above the knee. 

I have already, in my remarks on the treatment of fractures in general, 
declared my acceptance of the so-called u immovable apparatus " in the 
treatment of certain fractures of the leg below the knee, and especially of 
the plaster-of-Paris dressings. In hospital practice, where these dress- 
ings can be applied by experts, and where the limb can be watched daily 
and hourly, most or all of the dangers incident to this form of dressing 
may be avoided ; but even here I have occasionally seen, from a little 
too much delay in opening the dressings, serious trouble ensue. Its most 
devoted advocates, Seutin, Velpeau, and others, have never denied the 
necessity of caution in its use. On the other hand, when applied judi- 
ciously, even immediately after the receipt of the injury, and when care- 
fully watched and opened freely on the first notice of danger, it has, in 
my wards, and in the hands of my excellent house surgeons, often served 
its purpose more completely than any other apparatus or splints I have 
even seen employed. It has steadied and supported all parts of the limb 
more completely, and permitted it to be handled more freely, than any- 
thing else could do. In simple fractures patients have been permitted 
to walk about upon crutches after the third or fourth day, and generally 
no harm has resulted. In one case, however, I believe this liberty caused 
a serious delay in the union ; and in another an abscess resulted, which 
would have been avoided if he had remained in bed. 

Inasmuch, however, as among the claims lately instituted for the plaster-of- 
Paris dressing, it has been affirmed by at least one surgeon that it is competent 
to prevent in all cases shortening after fractures of the bones of the leg, as well 
as of the thigh (see chapter on General Prognosis), it may be necessary to refer 
the question at once to the test of experience, and thus dispose of it before con- 
sidering the subject of treatment. 

F. A., set. 24, fell, breaking his left leg three inches above the ankle, and was 
admitted to Bellevue. Dr. Thomas, while the limb was extended to its utmost, 
applied the plaster-of-Paris dressings from the toes to the knee. The dressings 
were removed in my presence, at the end of six weeks, when the bones were 
found united with a shortening of one inch. 



FRACTURES OF THE TIBIA AND FIBULA. 477 

T. M., aet. 30, fell and broke his left leg by a twist of his foot. Fracture 
simple, oblique, and in lower third. Plaster-of-Paris was applied at once, while 
extension was made to the utmost. The splint was renewed once during the 
treatment, and on the 19th of April, the splint being removed, I found the limb 
united, and shortened three-quarters of an inch. 

These two cases will serve to illustrate what has been my experience at Bellevue 
and elsewhere with the plaster-of-Paris as a means of extension. Of fifteen cases 
of oblique fractures of the shaft in my record, the average shortening is nearly 
three-quarters of an inch, and all are shortened. It is not the practice gener- 
ally at Bellevue to give an anaesthetic in applying plaster to the leg, nor is it 
mentioned as having been used in more than one of the cases contained in Dr. 
Van Wagenen's tables, referred to in the chapter on General Prognosis. But, 
to determine the value of this method in a case of simple oblique fracture of 
both bones, I first measured the limb carefully before it was dressed, and found 
it shortened half an inch. The patient was then placed under the influence of 
an anaesthetic, and forcible extension made with pulleys until the limb was of 
the same length as the other. In this position it was retained until the plaster 
w T as applied, from the toes to above the knee, and had hardened. At the end of 
about six weeks the dressings were removed, and the limb was found to be short- 
ened half an inch precisely the same as before the extension was employed. 

It is certain that this form of dressing makes no permanent extension within 
a range of three-quarters of an inch, and that, therefore, for all practical pur- 
poses, as a means of preventing shortening, it is useless. 

The following careful description of the proper mode of applying plaster-of- 
Paris bandages in fractures of the leg, has been prepared at my request by Dr. 
S. B. St. John, late House Surgeon to Bellevue Hospital. His large experience 
and his habits of accurate observation render his statements peculiarly trust- 
worthy. "The materials necessary are blanket or cotton-wadding, blanket- 
being preferable, and plaster-of-Paris bandages, which are prepared by rubbing 
dry plaster into the meshes of a bandage of coarse texture, and rolling it up so 
as to make it convenient of application. (These may be kept ready for use in 
tin cans.) The bones having been placed in position, the leg is placed upon the 
blanket, which is cut and folded neatly around it, and secured by a few pins. 
The blanket should extend from the base of the toes to the knee, or in case of 
fracture above the middle, or of compound fracture at any point, a few inches 
above the knee. The plaster bandages should then be immersed in hot water, 
to which a little salt has been added to hasten the setting, and while in the 
water they may be gently kneaded to insure moistening of every part. In about 
three minutes, or when bubbles of air cease to rise from them, they will be ready 
for use, and should be taken out as they are wanted, and gently squeezed to get 
rid of superfluous water. They are then to be applied after the fashion of an 
ordinary bandage, over the blanket, with just sufficient firmness to insure a 
complete fit. If, at any revolution of the bandage, the plaster is seen to be dry, 
it should be moistened by dipping the hand in water and rubbing it over the 
dry surface. Extra turns of the bandage should be taken at the places where it 
is necessary to secure extra strength to the splint. Three or four bandages (six 
yards long) are usually sufficient to make a firm splint. This splint will usually 
be sufficiently pliable just after its application to allow of rectification of any 
faulty position which may have occurred during its application. It should then 
be kept in shape by the pressure of the hands until it hardens, which will be in 
from ten to thirty minutes, according to the freshness of the plaster and texture 
of the bandages used. If, for any reason, it is desirable to cut the splint so as 
to admit of its removal, or to cut a fenestra through which to observe any part, 
this may best be done before the plaster becomes perfectly dry, say in from two 
to five hours after its application, depending upon the quality and freshness of 
the plaster. It will then cut like hard cheese, and a stout, sharp knife should be 
used. In splitting a splint anteriorly, it is convenient at the same time to take 
out a piece about an inch wide, by making two parallel cuts one inch apart, one 
on either side of the median line, extending nearly through to the blanket, and 
then by raising the strip at the upper edge and cutting on either side alternately, 
the section may be completed, and the central slip removed without danger of 
cutting through the blanket and w T ounding the patient. The blanket may then 



478 



FRACTURES OF THE TIBIA AND FIBULA. 



be cut with scissors and the splint sprung off to examine the limb, if necessary. 
When replaced, a bandage should be applied over it. If it should be necessary 
to cut a splint which has already become dry, and cuts with great difficulty, it 
may be softened with hot water, applied by a sponge in the track of the proposed 
section for ten or fifteen minutes. 

" If it is necessary to cut such a large fenestra that only a small strip of the 
splint would be left connecting its upper and lower, portions, it is better to adopt 
a different plan of application. For this it is necessary to have a solution of 
plaster- of-Paris in water of the consistency of cream. A piece of blanket is 
then cut long enough to reach from the toes to the top of the proposed splint, 
and about fifteen inches wide. This is to be thoroughly soaked in the solution, 
and folded several times so as to be about two or three inches wide when folded. 
This is to be applied along that part of the limb which it is not necessary to 
keep under observation (if convenient, along its posterior aspect), and it is then 
to be secured in position by circular turns of the plaster bandage above and 
below the portion to be left exposed. Whenever a plaster apparatus extends 
above the knee, and it is proposed to sling the leg from a cradle, the leg should 
be flexed slightly upon the thigh, so that it may be swung horizontally. Any 
portion of a plaster splint exposed to the moisture of discharges or of water 
used in dressing should be carefully protected by oil silk and cotton-wadding. 
In cases where not much swelling is anticipated, blanket is preferable to cotton- 
wadding, as an elastic medium between the splint and skin, because it is of 
more even thickness and retains its place better when the splint is removed, but 
cotton answers better when much swelling is anticipated, as being more elastic." 

Fig. 308. 




Plaster-of-Paris dressing, and suspension. 



The accompanying illustration (Fig. 308) has also been made for me by Dr. 
St. John, and furnishes a faithful picture of one of the many similar cases which 
have been under treatment by this method at Bellevue Hospital. 

Dr. George A. Van Wagenen, while acting as house surgeon at Bellevue, devised 
a most ingenious, simple, and effective apparatus for suspending the limb, which 
will be found illustrated in the accompanying woodcut (Fig. 309). " It consists 
of an elbow ~\ of wood projecting over the foot of the bed, from which the leg 
is suspended by two pieces of rubber tubing ; one above the ankle, the other 
just below the knee. The tubes have common grooved iron pulleys or wheels at 
each end ; those above, rolling on a large iron wire to allow motion toward the 
head or foot of the bed ; those below, at right angles to the others, holding the 
rings of rope in which the leg rotates ; this last being far the most important, 
allowing the patient to turn on either side. Motion on these rollers is accom- 
plished with so little resistance that there is no pain. 

" The upright of the elbow to go at the foot of the bed should be long enough 
to rest on the floor, or any convenient part of the bedstead, and project about 
two feet above the level of the mattress— the horizontal piece long enough to 
reach nearly to the knee ; pine f by 2 inches is heavy enough. The angle made 
by these pieces is braced, and a strap of hoop-iron outside makes it very strong. 
In the horizontal piece two slots are cut wide enough to allow the iron pulleys 
to pass through, and of sufficient length to allow the patient to draw himself 



FRACTURES OF THE TIBIA AND FIBULA. 



479 



up and down in bed. A -g- inch iron wire passes the whole length of this piece 
above the slots, steadied by small staples, so that it may be withdrawn. On this 
the upper pulleys run. The wire shields I I above these slots are to prevent 
the bedclothes from resting upon the rollers. 



Fig. 309. 




Van Wagenen's suspension apparatus 



" The pulleys or wheels are fastened in the rubber tubes by making a few 
turns of copper wire around the iron screw of the pulley. This is pushed into 
the tube and bound outside with fine wire. 

" Rings of rope large enough to pass over the foot are then put through the 
lower pulleys. If these rings open, or the foot is slipped out of them, the leg 
is taken down without any of the apparatus about it, and the large wire may be 
withdrawn and the leg lowered, with the pulleys and rings still attached." 1 

Fig. 310. 




G. Wackerhagen's method. 

There are a few cases in which a very much better position of the frag- 
ments can be secured by placing the patient under the influence of an 

1 Van Wagenen, Med. Record, April 1, 1873. 



480 



FRACTURES OF THE TIBIA AND FIBULA, 



anaesthetic, and by applying the dressings during complete anaesthesia. 
But the surgeon needs to be warned of two things in this connection : 
First, that just as much harm can be done to the soft parts by violent 
wrenching and pushing when the patient is insensible as when he is fully 
conscious ; second, that while the patient is passing under the influence 
of an anaesthetic he is liable to violent muscular spasms, which may do 
serious injury. 

What is known as the Bavarian method of using plaster-of-Paris has 
been adopted by some American surgeons, which consists essentially in 
leaving the splint open in front and behind, or in leaving it connected 
posteriorly only by a strip of cloth, which serves as a hinge. This plan 
has been especially recommended by Dr. G. Wackerhagen, of Brooklyn, 
N. Y. By this method all danger of strangulation is avoided. As 
between this plan and the use of sole leather, which can be made to fit 
as accurately, or nearly so, as plaster-of-Paris, it is, therefore, a question 
of convenience rather than of practical utility. 

[The Bavarian splint or some modification of it is one of the best as well as 
simplest dressings for fractures of the leg. In its simplest form this splint con- 
sists of two pieces of heavy flannel cut to fit the limb, but sufficiently large more 
than to envelop it ; they are now stitched together by a straight seam along 
the back ; then this dressing is placed under the limb and the inner layer is 
folded evenly around the part and secured by long pins or stitches (Fig. 311) ; 
while the leg is held firmly in position mix the plaster-of-Paris with about an 
equal bulk of water and rapidly apply it, partly by pouring it over the outer 
layer of flannel and partly with a spoon ; now quickly bring 
the two portions of the outer layer over the limb so as to 
meet, and smooth them with the hands so as to remove the 
inequalities in the distribution of the plaster before it 
hardens ; the edges are to be trimmed and the pins removed ; 
the splint is maintained in position by a firm roller applied 
to its whole extent. On removal, to examine the limb, the 
dressing opens in front like a book, while the seam at the 
posterior part acts as a hinge. 

Mr. Bryant states that a similar dressing is in general use 
in Guy's Hospital, London, and illustrates its application 
quite elaborately. Coarse " house-flannel " which has been 
shrunk is selected ; two equal-sized pieces are first cut long 
enough to reach from the lower border of the patella to three 
inches below the heel, and in breadth about six inches more 
than the circumference of the calf, so as to allow the edges to 
overlap about three inches when the flannel is folded round 
the leg. One of these pieces should now be applied to the 
leg, its centre corresponding with the centre of the calf, and 
its two flaps brought tightly together over the skin (Fig. 
312), where they should be firmly stitched together from the 
upper part down to the hollow of the instep ; holding the 
foot at right angles and dragging the flannel tightly down- 
ward, stitch the sole from the toes to the heel ; finally stitch 
the remaining piece along the dorsum of the foot. The 
flannel along the sole of the foot to within an inch of the 
stitches should next be cut off and the edges turned back; the superfluous 
flannel along the front of the leg and dorsum of the foot should be used to sling 
the leg in the cradle. The next step is to apply to the flannel a paste made of 
precipitated chalk and mucilage of gum acacia, stirred to the consistence of 
honey (or plaster-of-Paris); use the hand or a brush so as to spread it evenly 
and make it enter all the inequalities of the flannel. Now apply the outer 
layer of flannel, placing it just as the first was placed, with its centre corre- 




The Bavarian 
splint ; the first 
piece of flannel ap- 
plied and the sec- 
ond ready for the 
plaster. 



FRACTURES OF THE TIBIA AND FIBULA. 



481 



sponding with the median line of the calf, folding its edges around the leg and 
bringing them up together in front over the edges of the previous layer, and 
retaining it by stitches at intervals down the leg close to the skin. When the 
dressing is dry the limb is removed from the cradle, and the splint removed 
from the leg and dorsum of the foot by cutting up the stitches along the front, 
and then forcibly separating the edges of the flannel. The edgesof the splint 
may then be bound, eyelets made for tape, when it may be reapplied and laced 
firmly in its position. 



Fig. 312. 



Fig. 313. 





Bryant's dressing ; a, first layer of flannel applied to 
the limb; b, second layer about to be applied. 



Bavarian splint completed. 



This form of splint applied in fractures of the upper part of the tibia, or into 
the knee-joint, is very serviceable. It is an immobile removable splint. (Fig. 
313.) 

A gypsum splint is recommended by Croft, of London, as follows : Select a 
piece of house flannel, or an old, thin, shrunk blanket, or any suitable substi- 
tute ; shape the pieces by measurement, taking the circumference of the limb 
below the knee, at the biggest part of the calf, just above the ankle-joint, from 
the front of the ankle-joint round the heel to the front again, and at the middle 
of the metatarsus ; the flannel of each splint should be in width half an inch 
less than half the circumference at any of those points ; the width of the two 
splints should be one inch less than the circumference of the limb at any cor- 
responding part, and long enough to extend from the tubercle of the tibia to 
the middle of the metatarsus ; four pieces are required, two for each splint ; 
prepare two bandages of common muslin each five to six yards long and two 
inches and a half in width ; mix about a handful of good dry plaster with water 
to the consistence of thick cream; lay the inside pieces of flannel on the table 
or bed, the outer surface being upward ; soak the outside pieces in the plaster 
separately and lay them out on their respective inside pieces. Whilst traction 
is kept up, and the ends of the broken bones are maintained in apposition, the 
splints are to be applied and smoothed ; then the bandage is to be put on ; trac- 
tion is to be maintained during the hardening of the plaster ; then the limb 
should be laid on a large soft pillow, the toes directed upward and the knee a 
little bent. Great caution should be taken that the bandage is not drawn tightly 
anywhere, and that no one turn is tighter than another. The two splints should 
not meet each other by about half an inch in front or behind, the intervals 
being spanned by the dry, porous muslin. At the sides the bandage is fixed to 
the splints by the plaster which oozes into it from the outer layer of flannel. 
When it becomes necessary to inspect the limb the bandage can be split up along 
the middle line in front, and the dressing opens as it is hinged by the muslin 
bandage which spans the interval behind.] 

In such few cases as demand or warrant a resort to permanent exten- 
sion and counter-extension, a double inclined plane furnishes a conve- 
nient mode for its accomplishment ; but it is only occasionally that, in 
fractures of the leg, permanent extension and counter-extension can be 
employed ; an assertion which, however much it may surprise the inex- 
perienced, observation will prove to be true. If the fracture is near 

31 



482 



FRACTUKES OF THE TIBIA AND FIBULA. 



the middle of the leg, quite remote from the points upon which the 
appliances for extension, etc., are to be made fast, and the inflammation 
is moderate, something may be done in this way ; but when the point of 
fracture approaches the ankle-joint, as it actually does in a great majority 
of cases, a gaiter, made of any material whatever, if it has sufficient 
firmness to overcome completely the action of the muscles, will inevitably 
cause congestion and swelling, accompanied sooner or later with great 
pain and with ulcerations, and simply because the extension is made 

Fig. 314. 




Ililtlil 



James Hutchinson's splint, for extension, etc., in fractures of the leg. (From Gibson ) 

directly upon parts already tender and inflamed from the accident itself; 
and when we add to this complete and violent ligation of the limb near 
the seat of fracture, a similar ligation of the limb just below the knee, 
for the purpose of making counter-extension, we are prepared to under- 
stand how the worst consequences may ensue. 

Neill, of Philadelphia, and others have sought to overcome some of the diffi- 
culties in the way of making extension in fractures of the legs, by substituting 
adhesive plaster for the usual extending or counter-extending bands. Says Dr. 
Neill : " For simple fractures of both bones of the leg, attended with shorten- 
ing and deformity not easily overcome, the limb should be placed in a long 
fracture-box with sides extending as high as the middle of the thigh, and a 

Fig. 315. 




John Weill's apparatus for fractures of the leg requiring extension and counter-extension. 

Pillow should be used for compresses. The counter-extension is made by strips 
of adhesive plaster, one inch and a half in breadth, secured on each side of the 
leg below the knee, and above the seat of fracture by narrower strips of plaster 
applied circularly. The end of the counter-extending strips may then be 



FKACTURES OF THE TIBIA AND FIBULA. 



483 



secured to holes in the upper end of the sides of the fracture-box, by which the 
line of the counter-extension is rendered nearly parallel with the limb. The extension 
is also to be made by adhesive strips, in a mode which is now well known and 
understood. The ends of the extending bands may be fastened to the foot- 
board of the box." 1 

Dr. Neill further remarks : " In compound fractures of the leg, shortening 
and deformity are often difficult to overcome, as is well known to experienced 

Fig. 316. 




John Weill's apparatus for compound fractures of the leg. 

surgeons. In such cases we may wish to dress the wounded soft parts, and, at 
the same time, maintain a certain amount of extension and counter-extension. 
This can be readily accomplished by having the sides of the fracture-box sawed 
in two parts at the knee, so that the sides of the box above the knee, from the 
upper end of which the counter-extension is made, need not be disturbed during 
the dressing, while that portion of the side of the box corresponding to the leg 
may be opened at pleasure without diminishing the tension of the extending or 
counter-extending bands." 

In compound fractures of the leg, Dr. Gilbert recommends a modification of 
the common fracture-box. In this apparatus the foot-board is omitted, and a 
block for the reception of the frame of the tourniquet is substituted. Each side 
of the box consists of three separate segments. Of these the upper and lower 
are permanently screwed to the bottom board, and the central one is attached by 
hinges. By this arrangement there is full access to the wound, which may be 

Fig. 317. 




• Gilbert's box for compound fracture of the leg. 

1. The four counter-extending adhesive strips, as if encircling the knee and upper part 
of leg. 2. The two extending adhesive strips crossing at the bottom of the foot, ready to 
be applied to the foot. 3. Tourniquet. 

dressed from day to day without disturbing the extension and counter-extension 
maintained by the permanently attached upper and lower segments. 

The following woodcuts are intended to illustrate an apparatus invented by E. 
O. Crandall, for the purpose of making permanent extension. The extension 
is represented as being made by a gaiter, but Dr. Crandall leaves it to the choice 
of the surgeon whether he shall employ the gaiter or adhesive strips. 2 



1 Philadelphia Med. Exam., vol. xi. p. 580, 1855. 

2 Crandall, Phil. Med. Journ., vol. iv. p. 193, Jan. 
Southern and Central New York, 1855, pp. 81, 82. 



1856 : also Transac. of Med. Assoc, of 



484 



FRACTURES OF THE TIBIA AND FIBULA. 



Without intending to deny to these contrivances for permanent ex- 
tension much ingenuity and some little practical value, I am far from 
conceding that they will be found capable of overcoming the action of 
the muscles where the ends of the fragments do not support each other. 
Their mode of action is such that they can scarcely do more than to 
steady the limb, and if they operate upon the fragments at all in the 
direction of their axes, it must be only in the most inconsiderable degree. 
The adhesive nlasters are substituted for the circular knee-bands and the 



Fig. 318. 




Section of Crandall's apparatus, applied to the limb; showing adhesive plaster, 
counter-extending bands, and gaiter for extension, etc. 



gaiters, with a view to avoid 



igation 



but in order to do this they must 



not encircle the limb, but only be laid parallel to its long axis. The leg 
of an adult, or that portion to which the adhesive plasters can be applied, 
supposing the fracture to be exactly at the centre, may be sixteen inches, 
that is, eight inches for extension and eight for counter-extension ; but 
when we employ the same means for extension in fractures of the thigh, 
we find it necessary to apply the strips over the whole of these sixteen 
inches, the entire length of the leg, or they will not hold. It will be 

Fig. 319. 




Crandall's apparatus complete. The counter-extending straps are passed over a block o 
wood, supported above the knee, to prevent their pressure upon the sides of the knee. 

apparent also that we cannot use even the eight inches which we have, 
for the purpose of argument, allowed these gentlemen in fractures of the 
leg. There must be at least a space of eight inches between the ends of 
the two opposing strips in order that they may operate at all upon the 
fragments ; indeed, I do not believe that even then their influence would 
reach beyond the skin to which they were directly applied ; but if a 
space of eight inches is left, only four remain for the strips at either 
end ; and this is an amount of surface wholly insufficient for our purpose. 



FRACTURES OF THE TIBIA AND FIBULA 



485 



What, then, shall we do when the fracture is near one of the extremities 
of the bone ? These gentlemen seem to have forgotten, moreover, that 
the whole leg is tender, and that the skin easily vesicates. In short, 
they have not seen the many points of difference between the application 
of these means in fractures of the thigh and leg, and which, while they 
allow us to accomplish all that we could desire with the one, are of little 

Fig. 320. 




Posterior view of the lower portion of CrandalPs apparatus. 

or no use in the other. We shall then always come to the same conclu- 
sion : whatever means we may employ to make permanent extension in 
fractures of the leg, we must either fail to accomplish all that we desire, 
or incur the hazards incident to complete and firm ligation of the limb ; 
and if the preference is given to any form of apparatus to accomplish 
these ends, it must be to some form of the double-inclined plane, by which 
we may at least avoid ligation in the upper part of the limb, the counter- 
extension being made against the under surface of the thigh, while it is 
resting upon the thigh-piece ; or to one of the long straight thigh-splints, 
which will enable us to make the counter-extension from the thigh and 
perineum. 

If a double inclined plane is used, I prefer either a plain apparatus, 
such as we have already described as in use for fractures of the thigh, 

Fig. 321 . 




-^ 



Liston's double inclined plane, applied to the leg in case of compound fracture. 

(From Miller.) * 



constructed of boards, joined together by hinges opposite the knee, and 
with an upright foot-board, upon which a carefully-arranged and thick 
cushion has been placed ; or the more elegant double inclined plane of 
Liston. 

In using Liston's apparatus, it must not be inferred that the knee is 
always to be bent. The apparatus is designed to be used occasionally 



486 



FRACTURES OF THE TIBIA AND FIBULA. 



as a straight splint ; and there will be found many cases of fractures of 
the legs in which the straight position will be most suitable: this is espe- 
cially true of such fractures as, occurring just below the knee-joint, have 



Fig. 322. 




Louis Bauer's wire splints for the 



the line of fracture directed obliquely downward and forward. But there 
are many compound fractures which demand the same extended position ; 
and in nearly all cases where this form of apparatus is used as a double 
inclined plane, the lower end of the splint should be elevated so that the 
heel shall not be much below the level of the knee. 



Fig. 323. 




Swing box or " cradle." (From Skey.) 

Bauer's wire splints, used also for side-splints, when they are formed 
to fit the limb accurately, possess some advantages which must recom- 
mend them to the attention of surgeons ; but neither these splints nor 
any other, however accurately fitted, ought to be applied directly to 
the naked skin. They require always the interposition of a well-padded 
lining. 

1 Bauer, Buffalo Medical Journal, April, 1857, vol. xii. 



FRACTURES OF THE TIBIA AND FIBULA. 



487 



Boxes are rarely useful except in certain compound fractures. They 
are heavy and awkward machines, which prevent the patient from moving 
readily in bed ; or which, being fixed, if he does move, allow the upper 
fragment only to descend, or to move upon the lower as a fixed point. 



Fig. 324. 




Salter's cradle. (From Fergusson.) 

If used at" all, they ought generally to be suspended, or made to move 
on a suspended railway. But however they are arranged, the limb is a 
great part of the time concealed from sight, and the surgeon is prevented 
from making use of such means to rectify deviations in the line of the 
bone as he would probably have otherwise employed. 

The swing invented by James Salter, of London, is constructed so as to allow 
not only a lateral motion, but also a more complete motion in the direction of 
the axis of the limb, by which the danger of pushing the fragments upon each 



Fig. 325. 



Fig. 326. 




John "W. Trader's suspension apparatus for compound 
fractures. 



Fracture-box, with movable 
sides. 



other is obviated. This is accomplished by the rolling of two pulley- wheels 
upon a horizontal bar. The case in which the leg rests may be made of metal 
or of wood, and the frame of iron, for the sake of lightness and strength. 

Dr. Hodgen, of St. Louis, suspends the box over a pulley placed transversely, 
so that by drawing the rope to the right or to the left, the box may be turned 



488 FRACTUKES OF THE TIBIA AND FIBULA. 

upon either side. The suspension apparatus devised by Trader, of Sedalia, Mo. 
for the treatment of compound fractures of the leg, when it is desired to employ- 
irrigation, I have found very useful in my wards at Bellevue. The limb is sus- 
pended by transverse strips of cloth, over a tray, from which the water is con- 
ducted by nozzles. I have found it convenient to attach India-rubber tubing to 
these nozzles, through which the water may be conveyed to a pail placed beside 
the bed. We have used it satisfactorily, also, for other cases than fractures. 

Fracture-boxes, employed in the treatment of compound fractures of the leg, 
are, in this country, sometimes filled with bran ; the bran being closely packed 
upon all sides so as to support the limb uniformly and gently. This method of 
treating compound fractures of the leg was first suggested by J. Rhea Barton, of 
Philadelphia, 1 and has been much used in the Pennsylvania Hospital; and more 
lately it has been introduced into the Bellevue and New York City Hospitals. 
It possesses the advantage of affording a perfect protection against flies in the 
summer season, and of absorbing the matter as it escapes. In using the "bran- 
box," the sides are first brought up into position and made fast. A piece of 
muslin cloth, one yard in length by half a yard in breadth, is then laid upon the 
box, and into this the bran is poured, until it is about one-fourth full. The bran 
is then distributed so as to fit the back of the leg, and the limb is placed in posi- 
tion. After which, additional bran is packed on either side of the limb, until it 
is nearly or quite enveloped ; the wounds being first covered by pieces of lint 
smeared with simple cerate. Finally, the upper portion of the muslin sack is 
fastened around the limb just above the knee, to prevent the escape of the bran. 
Whenever any portion of it becomes soiled by blood or pus, it may be dipped 
out with a spoon, and its place supplied with fresh bran. The support which it 
gives to the limb is also uniform without being at any time excessive. 

[The fracture-box with bran is now an antiquated contrivance designed to 
meet conditions of suppuration which do not exist in the practice of any com- 
petent surgeon. It is occasionally employed, however, but its presence indicates 
ignorance of the principles which now govern in the treatment of open wounds.] 

In whatever position the leg is placed, and with many of the forms of 
apparatus enumerated, it will be found necessary to protect the limb from 
the weight of the bedclothes by some contriv- 
Fig. 327. ance similar to that figured in the accompany- 

ing drawing ; or by a rack, such as is repre- 
sented for suspending the leg when leather 
splints or the immovable apparatus is em- 
ployed. 



Malgaigne, who declares that every surgeon knows 
Wire rack for fracture of leg. h()w imp 5 ssible it is> in an immen se majority # of 

cases, to overcome the projection of the superior 
fragment when the limb is placed in the extended position (over a double in- 
clined plane), and who affirms that neither Pott's position, nor Dupuytren's 
modification of it, will do much if any better, nor, indeed, that Laugier's plan 
of cutting the tendo Achillis possesses in this respect any real advantage, con- 
cludes at last to resort to a new and really ingenious method, the value of which, 
also, he claims to have already fully demonstrated. His apparatus consists simply 
of a steel band of sufficient size to encircle three- fourths of the limb, at the two 
extremities of which are two horizontal mortises through which a band is passed, 
and which may be buckled upon itself behind. The centre of the metallic arch, 
in front, is penetrated with a firm metallic screw, terminating in a very sharp 
point, and which is moved by a flat thumb-piece. The limb being laid over a 
double inclined plane, and the pads being carefully adjusted, as we have already 
directed when speaking of other forms of apparatus, and the limb properly ex- 
tended, the apparatus of Malgaigne is placed over the limb, with the sharp point 
of the screw resting upon the upper fragment, a few lines above the point of 

1 Barton, Amer. Journ. of Med. Sci., vol. xvi. p. 31, and vol. xix. p. 515. 




FRACTUKES OF THE TIBIA AND FIBULA. 



489 



fracture ; and at the same moment that this point is pressed firmly down to the 
bone, the fragments being held together by an assistant, the strap is buckled as 
tightly as possible under the splint. A few turns of the screw will now make 



Fig. 328. 




Malgaigne's apparatus for oblique fractures of the leg. (From Malgaigne.) 

its point penetrate more deeply into the bone, and insure the most complete 
apposition of the broken extremities. " This is accomplished," says Malgaigne, 
" with very little pain to the patient ;" and, as will be seen, the steel arch effect- 



Fig. 329. 




Malgaigne's apparatus applied. (From Malgaigne.) 

ually prevents any ligation of the limb. I cannot say the plan receives my un- 
qualified approval ; yet I have employed it to advantage in some cases of old 
ununited fractures. 

[In obstinate cases of overriding the surgeon is justified in wiring the bones 
antiseptically.] 

Treatment of Delayed or Non-union. — It has already been remarked 
that pretty frequently in this fracture union is delayed considerably 
beyond the usual period of six or eight weeks, but that in a large majority 
of these cases of delayed union consolidation is finally accomplished 
without any surgical operation. This is most often effected by permit- 
ting the patient to rise and go about on crutches, the fragments being 
supported by some light but firm splint, which will permit also the limb 
to be opened daily and washed or rubbed gently, so as to restore its cir- 
culation. In some few cases, after the lapse of several months, if this 
method has not succeeded, the bones have been known to unite firmly in 
a year or two, without side-splints, and even when the patient has been 
bearing his weight upon the limb. But such a result is rare, and is 
scarcely to be expected. If, indeed, the union is not effected within four 
or five months with the splints and crutches, it is better to resort at once 



490 FRACTURES OF THE TIBIA AND FIBULA. 

to perforation between the fragments, as has been directed in the general 
chapter on Delayed or Non-union of the Bones. A few illustrative 
examples will serve, perhaps, to enforce these statements. 

J. C, set. 28 years, was admitted to Bellevue Hospital with a simple fracture 
of the leg below its middle. The limb was placed in a fracture-box, but not 
suspended, where it remained six weeks. A starch bandage was then applied, 
and continued two months. About the middle of February the fragments were 
perforated, and the starch bandage again applied. March 3d I substituted 
leather splints for the starch, and directed him to go about on crutches. April 
2d, finding that union had not taken place, I perforated the fragments thoroughly, 
applied the splints, and allowed him again to use his crutches. A few months 
later bony union had taken place. 

M. W. set. 28 years, was admitted to Bellevue with a simple fracture of the 
leg near the upper end of the lower third. Within one week it was inclosed in 
a plaster-of- Paris dressing. At five weeks there was no union. The plaster splint 
was renewed, and she was allowed to go about on crutches. No bony union at 
ten weeks. Splints and bandages were then removed, and she continued to walk 
with crutches, and in one month the union was firm. 

C. H., set. 36 years, had his left leg broken — fracture comminuted. A surgeon 
placed the limb in a "bran box" until the swelling had subsided, and then 
applied a plaster-of-Paris dressing, which was removed in four weeks. The 
fibula had united, but not the tibia. The splint was kept on, and he was allowed 
to go upon crutches. Eight months after the accident found the limb much 
wasted, and no bony union of the tibia. He was advised to lay aside his crutches 
and to remove the splints, and to walk about, except that he was permitted 
occasionally to use crutches. In about four months the union was firm, the limb 
being a little bent outward at the seat of fracture, and shortened three-quarters 
of an inch. 

The following is the only case I can recall in which I have found these bones 
ununited at the end of a period so long as four years : A gentleman, set. 33 years, 
was struck by a billet of wood, breaking his left leg just below the knee. The 
fracture of the tibia was transverse. His surgeon dressed the limb on a double 
inclined plane. Four years later he consulted me, when I found the bones still 
ununited, although he was in perfect health, and had been constantly using the 
limb. I advised perforation, but he did not consent. 

In Dr. Muhlenberg's tables of delayed union and ununited fractures, in a total 
of 94 examples involving both bones, 71 were finally cured, 3 were relieved, 19 
failed, and 1 died. It might be more proper to say 71 were cured, and 23 failed. 
Of these, 10 were cured by friction, 26 by mechanical appliances and immobili- 
zation, 4 by seton, 20 by resection, and 10 by drilling. 1 died after resection. 1 

Resection and Refracture of Crooked Legs. — In some cases of extreme 
deformity of the legs consequent upon badly united fractures, resection 
of the bones has been practised with more or less success. 

Gurlt, 2 in a record of 25 resections for badly-united fractures of these bones, 
reports 19 as cured, 2 deaths, 1 amputation, and 2 failures. 

More often cases are presented of badly-united fractures of the leg, 
which seem to justify a resort to refracture ; and, while this procedure 
is attended with little or no danger to life, after neither resection nor 
refracture can we always make sure of a reunion. If, moreover, the 
surgeon expects, by a refracture, to lengthen a limb much, where it is 
merely overlapped and shortened, he is, I am certain, destined to dis- 
appointment, at least in all cases where sufficient time has elapsed for 
the bones to have become firmly united. I have myself several times 

1 Muhlenberg, Agirew's Surg., vol. i. p. 866. - Poinsot, op. cit., p. 692. 



FRACTURES OF THE TARSAL BONES. 491 

refractured bones ; and I have several times met with cases of old frac- 
tures newly broken ; and I have constantly observed that I could never, 
in the end, make them but very little if any longer than they were before 
the refracture. The muscles had contracted and shortened, and their 
contraction could not be overcome. 

If, however, the object of the refracture is to straighten the limb, then 
no doubt it may be sometimes accomplished ; and in some degree also 
by the straightening of the limb the shortening may be overcome ; but 
in my opinion, such procedures ought to be reserved for extraordinary 
circumstances, unless the refracture can be made soon after the union 
has taken place. In those cases in which I have refractured the tibia 
and fibula after a recent union, the bones" have reunited promptly. 

In the case of a limb that had been broken eight weeks, and was quite 
crooked, but was not very firmly united, Dr. Horner, having refractured it, was 
able at once to restore it to a nearly straight line. 1 

T. B. J. had, his right leg broken near its middle. Ten years after the first 
accident he was thrown from a horse, and it was refractured at the same point, 
after which the tibia refused to unite. Six months later I advised perforation 
at the seat of fracture. Dr. Pancoast, of Philadelphia, subsequently brought 
about union by perforation, but extensive suppuration ensued, and the cure was 
not accomplished in less than six months. 



CHAPTER XXXIV. 

FRACTURES OF THE TARSAL BONES. 

Causes. — The astragalus is generally broken by a fall from a height, 
the patient having struck upon the bottom of the foot. Monahan, in an 
analysis of ten cases, found it had been broken by a fall upon the foot nine 
times, 2 and only once by a crushing accident. 

Shepherd, 3 of Montreal, has called attention to a fracture of the "little process 
of the astragalus external to the groove for the tendon of the flexor longus hal- 
lucis muscle," towhich is attached the posterior fasciculus of the external lateral 
ligament of the ankle-joint. He has met with four examples in the dissecting- 
room ; all of them without a history. The first was a man about 25 years old ; 
right foot ; and it had united to the main portion by fibrous tissue. The second 
was also in a young man ; right foot; with neither fibrous nor bony union. It 
remained attached to the posterior fasciculus of the external lateral ligament, 
but it was displaced slightly outward, and was quite movable. In the third case 
the process had been broken off; right leg; and it had become reunited by bone. 
The fourth case was found in a woman aged about 69, whose bones had under- 
gone fatty degeneration. The fragment had united by fibrous tissue. Dr. Shep- 
herd was unable to produce this lesion upon the cadaver ; but he calls attention 

1 Horner, New York Journ. Med., May, 1851, p. 432. 

2 Fracture of the Astragalus, with Analysis of the Recorded Cases of this Injury. An 
inaugural thesis presented to the faculty of the Buffalo Med. Coll , March, 1858, bv Bernard 
Monahan, M.D. 

3 Shepherd, Journ. Anat. and Physiology, vol. xvi. j> 79. 



492 FRACTURES OF THE TARSAL BONES. 

to the fact that this process is much more prominent in some persons than in 
others ; and furthermore, since in none of these cases was there a noticeable 
deformity of the foot, it would naturally be overlooked, or be regarded as a mere 
sprain. 

The calcaneum is also occasionally broken by violent lateral pressure, 
but much more often by a fall upon the foot, or rather upon the heel. 

Abel, 1 of Stettin, has called attention to a fracture of the little apophysis of 
the calcaneum (lesser process, or sustentaculum tali; the tubercle situated above 
the groove for the tendon of the peroneus longus, and called by Henle the 
"trochlear apophysis"), the apophysis being broken by a fall upon the foot 
when in the position of varus. Bidder' 2 has seen the same lesion, caused in the 
same manner, in a man 39 years old, and which he ascribed to the action of the 
perdneo-calcanean ligament (middle fasciculus of the external lateral ligament). 
After the lesion the foot becomes everted, and flattened as in valgus, and the 
length of the heel is apparently shortened by a slight displacement of the cal- 
caneum forward. 

In some instances both heel-bones have been broken at the same 
moment. 

Malgaigne has collected eight cases of fracture of this bone by muscular action, 
as in jumping upon the toes, the posterior portion of the bone being thus vio- 
lently acted upon by the tendo Achillis. South has mentioned two other cases. 
One received the injury by jumping off a stage-coach. The fragment was found 
to be drawn upward slightly, but not so far as to prevent crepitus when the mus- 
cles on the back of the leg were relaxed. The other is a cabinet specimen con- 
tained in the museum of St. Bartholomew's Hospital. The fracture had taken 
place just below the attachment of the tendo Achillis, but the upper fragment 
was not displaced. 3 Mr. Cooper mentions two other cases, both produced by 
violent efforts on the part of the patients to sustain themselves when falling. 
In one of these the fragment was immediately drawn up three inches. 4 Burg- 
graeve, 5 Coote, 6 Anningson, 7 and Poinsot 8 have met with the same accident from 
a similar cause. 

The other bones of the tarsus are generally broken by crushing acci- 
dents, such as the fall of heavy weights upon them, by the passage of 
loaded vehicles, etc. 

Pathology. — The astragalus often, indeed generally, escapes without 
injury in those crushing accidents which break many or most of the 
other bones of the foot, and, as we have seen, it is seldom broken except 
when the patient has fallen upon the bottom of his foot ; but at the same 
moment, the foot being turned forcibly out or in, a dislocation of the 
tibia takes place, and the fibula is broken. In nine of the cases collected 
by Monahan, one or the other of these forms of dislocation had occurred, 
in eight of which the dislocation was compound. The direction of the 
fracture is found to vary greatly ; thus, it has been found broken in its 
length antero-posteriorly, in its breadth or transversely, and in one in- 
stance it has been divided nearly horizontally, so as to separate the upper 

1 Abel, Arch, fiir klin. Chir., 1878, Bd. xxii. Hft. 2. 

2 Bidder, Cent far Chir., 3 881, p. 733 (Poinsot). 

3 South, Notes to Chelius's Surgery, p. 639, Amer. ed. 

4 B. Cooper's ed. of Sir Astley, Amer. ed., p. 311. 

5 Burggraeve, Bull. Acad. Roy. de Med. de Belgique, t. vi. p. 886, 1863. 

6 Coote, Thetanest, 1867, t. i. p. 270 (Poinsot). 

1 Anningson, Brit. Med. Journ., 1878, vol. i. p. 128. 
8 Poinsot, op. cit., p. 695. 



FRACTURES OF THE TARSAL BONES. 493 

face completely from the lower. Sometimes it suffers a species of im- 
paction, the fragments being actually driven into each other ; at other 
times, as in one case related by Amesbury, the bone may be split with- 
out the occurrence of any displacement. 

The calcaneum also may be broken in any direction, and it is equally 
with the astragalus liable to impaction, by which its vertical diameter is 
sensibly diminished, while its transverse diameter is increased. If the 
fracture is a consequence of muscular action, the line of fracture is 
always posterior to the astragalus, and in some cases only that portion is 
broken off to which the tendo-Achillis has its attachment. It may be 
broken also vertically, directly underneath the astragalus, in which case 
the lateral and interosseous ligaments will prevent anything more than a 
slight displacement of the posterior fragment. When the fracture takes 
place posterior to the lateral ligaments, the detached fragment is liable 
to be drawn very far from the body of the bone, even to the extent of 
four or five inches, and possibly farther when the leg is extended upon 
the thigh and the foot flexed upon the leg. 

Constance relates a case in which the tuberosity, having been broken off by a 
direct blow, was drawn up five inches. 1 

Fractures of the calcaneum produced by contraction of the sural 
muscles are generally simple, but those which result from a crushing 
of the bone are more often compound, The same remark is applicable 
also to the other bones of the tarsus, the fractures of which, being only 
produced by direct blows, are generally complicated with external 
wounds. 

Symptoms. — All fractures of the bones of the tarsus demand especial 
care in their diagnosis, since only a few of the usual signs of fracture 
are in a majority of the cases presented. The explanation of this fact 
will be found in the number, size, and strength of the bones of the 
tarsus, and in their close and firm union by ligaments, by which they 
give to each other a mutual support, so that the fracture of a single 
bone does not necessarily or usually result in displacement or deformity, 
and even crepitus is with difficulty detected ; and when we consider, 
moreover, that the fracture is generally produced by great violence, 
directly applied, in consequence of which the foot in most cases becomes 
rapidly and enormously swollen, we shall understand the true nature of 
the difficulties which are usually presented in the way of an accurate 
diagnosis. Of all the usual signs of fracture, crepitus alone is pretty 
generally present, but even this often fails to tell us which bone is broken, 
and still more often does it fail to inform us as to the direction and extent 
of the bony lesions. If the whole or a portion of the tuberosity of the 
calcaneum is separated by the action of the muscles, and the fragment is 
drawn upward, it may be discovered in its new position, and the heel will 
be flattened or shortened, but no crepitus can be felt unless the fragments 
are again brought in contact. 

1 Constance, Amer. Journ. Med. ScL, vol. v. p. 222, Nov. 1829, from the Midland Med. 
and Surg. Reporter. 



494 FRACTURES OF THE TARSAL BONES. 

Treatment.— Not any of the fractures of the tarsal bones in them- 
selves demand the use of splints, and it is only when complicated with a 
dislocation of the ankle and fracture of the fibula that it is proper to 
employ apparatus of this sort ; certainty the exceptions to this rule must 
be very rare ; so that our practice in these cases will be confined chiefly 
to the prevention and reduction of inflammation. This will be the sum 
of the treatment demanded during the first few days after the receipt of 
the injury in probably all cases of simple fracture, and in many cases of 
compound fracture. 

If single bones, or fragments of single bones, are displaced to any 
considerable extent, and there is an external wound communicating with 
the fracture, I have no doubt it would be best in all cases to remove at 
once by dissection the projecting bone, even although it were possible, or 
perhaps easy, to force it back again to its place, as has been done success- 
fully by Ashhurst, of Philadelphia. 1 The same rule I would apply to 
examples of fractures uncomplicated with any external wound, if the 
fragments were very much displaced, and could not by the application of 
moderate force be replaced, since the bone left to project would prevent 
the patient from ever wearing a boot with comfort, and would entail as 
much weakness upon the limb as would be likely to follow from its com- 
plete separation. But such cases as I have last supposed are exceedingly 
rare ; indeed, I have never met with a simple fracture of a tarsal bone 
accompanied by displacement. 

Norris has, however, reported a case of fracture of the astragalus accompanied 
by displacement of about one-half of the bone, but without any lesion of the 
soft parts. A man, set. 30, who was admitted into the Pennsylvania Hospital. 
An hour previous to admission, while descending a ladder, he slipped and fell 
in such a manner as to throw the entire weight of his body upon the outer part 
of his left foot. Upon examination, the foot was found to be turned inward 
and nearly immovable. A slight depression existed immediately below the 
lower end of the tibia, and there was a considerable hard and rounded projec- 
tion on the outer part of the foot, a little below and in front of the extremity 
of the fibula. The skin covering this projection was reddened, but not excori- 
ated. There was no fracture of either bone of the leg. These appearances led 
Drs. Norris and Barton, under whose care the patient was placed, to regard the 
accident as a simple luxation of the astragalus forward and outward ; and a 
short time after admission efforts were made to reduce it. " This was done, after 
relaxing in as great a degree as possible the muscles of the leg, by flexing the 
knee, and having assistants to keep up extension, by seizing the heel and front 
part of the foot, at the same time the bone being pushed inward and toward 
the joint by the surgeon. These efforts were continued for a considerable time, 
but had no effect in changing the position of the bone. Excision was per- 
formed. After removal it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and remained 
firmly attached to the extremity of that bone ; no attempt was made to extract 
it. Subsequently that portion of the astragalus which was permitted to remain, 
having become carious and loosened, was removed also. No healthy action 
ensued, and the patient soon died. 2 

Poinsot 3 has reported a case in which he practised resection. An insane 
woman, set. 40 years, had jumped from a second floor. Poinsot readily recog- 

1 Ashhurst, Amer. Journ. Med. Sci., April, 1862. 

2 Norris, Amer. Journ. Med. Sci., vol. xx. p. 379. 
a Poinsot, French ed. of this treatise, p. 699. 



FRACTURES OF THE TARSAL BONES 



495 




nized the displacement of a portion of the as- Fig. 330. 

tragalus of the right foot, which was accompa- 
nied with a marked deformity of the foot. 
There was no external wound. The extreme 
tension of the skin over the protruding bone 
determined him to proceed at once to remove 
the fragment, which was composed of the entire 
body of the astragalus exclusive of its neck. 
The fragment was rotated on its axis, so that 
its articular portion was directed downward and 
inward, and the broken surface presented to- 
ward the skin. The skin retained its relations 
to the scaphoid. A second fracture had sepa- 
rated by arrachement that portion which articu- 
lates with the malleolus internus. Both of 
these latter fragments were removed, the head 
of the astragalus only being permitted to re- 
main in place. Notwithstanding the utmost 
care to insure immobility, the indocility of the 
patient rendered this impossibible ; inflamma- 
tion and gangrene enused, and on the tenth day 
it became necesary to amputate. Death ensued 
two days later. 

"Mr. Hancock 1 obtained," says Poinsot, " a 
magnificent result in a carpenter, aged 47 
years, who presented a fracture of the astraga- 
lus ' at its inferior portion,' with displacement 
forward and outward. There was no wound; 
but the skin was so stretched on the displaced 
bone that gangrene was imminent. Mr. Han- 
cock immediately made, by excision, the total 
extraction of the astragalus. The wound was 
closed and dressed with lint dipped in a phenic 
acid solution ; the leg was put on a posterior 
splint with a foot-piece, and suspended in a Salter's crib. Phenic irrigations 
were made without interruption. When the first dressing was taken off, after 
eight weeks, the wound was completely filled up. Three months after the oper- 
ation the patient could lean on the injured foot, and walked easily with a high- 
heeled boot." 

[The former failures of resections in these cases are now no argument against 
a similar operation performed antiseptically. Hancock's success, with the use 
of phenic acid, proves the safety of the operation antiseptically performed.] 

A fracture of the posterior portion of the calcaneum, especially when 
it has been produced by muscular action, constitutes one exception to 
fractures of the tarsal bones generally, and demands usually that appa- 
ratus of some kind should be employed in its treatment. 

In order to replace the posterior fragment when displaced, or to 
maintain it in apposition until a bony union is accomplished, it may be 
necessary to shorten the gastrocnemii by flexing the leg upon the thigh 
and extending the foot upon the leg. But to retain the limb in this 
position it will be expedient always to employ apparatus. A very simple 
contrivance, however, will generally answer all the indications. A band- 
age, padded strap, or a stuffed collar may be fastened about the thigh 
just above the knee, and made fast to the heel of a slipper by a tape 
(Fig. 330). The apparatus is the same which has been recommended for 
a rupture of the tendo Achillis. 



Apparatus for fracture of the poste- 
rior extremity of the calcaneum. 



1 Hancock, Anat. and Surg, of the Human Foot, London, 1873, p. 251. 



496 FKACTURES OF THE METATARSAL BONES. 

In addition to this, the limb ought to be covered from the foot upward 
as far as the knee with a snug roller, underneath which, on each side of 
and above the detached fragment, ought to be placed suitable compresses, 
the object of the roller being to diminish muscular contraction, and the 
compresses being intended to retain the detached piece in contact with 
the main body of the bone. Some surgeons have not found it necessary 
to flex the leg upon the thigh ; but they have contented themselves with 
extending the foot upon the leg, and confining it in this position by a 
splint of wood or gutta-percha laid along the front of the leg, ankle, and 
foot. In still other cases, the fragment has shown so little disposition 
to become displaced as to render no precautions of any kind necessary, 
except to impose upon the patient complete quiet, with the limb resting 
upon its outside and flexed, as in Pott's fracture of the fibula. In this 
way I have once obtained a perfect union ; and in the case seen by Poin- 
sot, there being no displacement of the fragment, union was effected 
while the foot was only kept at rest in a pasteboard splint. 

In case, also, the sustentaculum tali is torn off, the foot should be kept 
in a position of dorsal flexion. 

All fractures of the tarsal bones demand that as soon as the inflam- 
mation has sufficiently subsided, passive motion should be given to the 
ankle, in order to prevent, as far as possible, the ankylosis which is an 
almost constant result of these accidents. Indeed, the patient is fortunate 
who recovers a tolerable use of his foot after the lapse of many months ; 
nor can he be assured that the inflammation will leave these bones and 
their dense fibrous envelopes for a long period, and that it may not 
result in caries of more or less of the tarsal bones, demanding finally 
amputation of the whole foot. 

I have not intended to speak in this place of those severer accidents, accom- 
panied with comminution and extensive laceration, which forbid the hope of 
saving the foot, and for which immediate amputation is the only proper resource, 
but which constitute, in fact, the great majority of all the fractures of the tarsal 
bones. 



CHAPTEE XXXV. 

FRACTURES OF THE METATARSAL BONES. 

These bones can scarcely be broken except by direct blows, and the 
great majority of their fractures are the results of severe crushing acci- 
dents, such as render amputation sooner or later necessary. Of those 
which do not demand amputation, by far the larger proportion are com- 
pound fractures. 

A man was run over by a loaded car, crushing his right arm so as to render its 
immediate amputation necessary. I found also a compound comminuted frac- 
ture of the fourth metatarsal bone of the right foot. Considerable hemorrhage 
occurred from the wound, but this ceased spontaneously. Cool water dressings 



FRACTURES OF THE METATARSAL BONES. 497 

were diligently applied, without splints or bandages, and although some inflam- 
mation and suppuration ensued, the parts finally healed over and the fragments 
united, with only a slight backward displacement at the seat of fracture. 

When only one bone is broken, the displacement is usually very trivial ; 
but when several are broken, it may be considerable. 

Malgaigne relates an example of this latter accident in which, the three mid- 
dle bones being broken by the wheel of a carriage, and the integuments being 
badly torn and bruised, it was found impossible to retain the fragments in place. 
The patient recovered, and was able to place the foot well to the ground, but the 
proximal fragments continued to project upward upon the top of the foot to 
such a degree as to require a special shoe. 

In a majority of cases the direction of the displacement is backward 
(upward), especially when the middle metatarsal bones are the subjects 
of the fracture. 

I have in my cabinet a second metatarsal bone broken obliquely near its mid- 
dle, with only a very slight displacement of the lower fragment backward ; and 
also the cast of a bone which has united with an enormous backward projection. 
In one instance I have seen the metatarsal bone of the little toe cut in two with 
an axe, and the fragments united in about thirty days, but with the lower frag- 
ments slightly displaced outward. Delamotte relates a case also in which the 
first four metatarsal bones were cut off, and complete union was accomplished 
on the fortieth day ; at the end of two months the patient walked without 
lameness. 

Treatment. — If the fragments are not displaced, nothing is required 
except that the foot shall be kept at rest, and the inflammation controlled 
by suitable means. In case, however, a displacement exists, it ought to 
be remedied, if possible, since, if only very slight, it may become the 
source of a serious annoyance. If the fragments project upward, they 
interfere with the wearing of a boot, and if they sink toward the sole, 
the skin beneath is liable to remain constantly tender, and the patient 
may thus be seriously maimed for life. 

In case the displacement is not due to the action of the muscles, but 
only to the nature and direction of the force producing the fracture, or 
to entanglement of the broken ends, and it is likely to cause any of the 
inconveniences which I have mentioned if permitted to remain, it will be 
advisable at once to employ considerable force in the way of pressure, or 
to elevate the fragments through an opening previously made upon the 
dorsum of the foot, calling to our aid even the saw or the bone-cutters, 
if necessary. After which the fragments may be retained in place by 
carefully-applied pasteboard splints and compresses. 



32 



498 FRACTURES OF THE PHALANGES OF THE TOES. 



CHAPTEE XXXVI. 

FRACTURES OF THE PHALANGES OF THE TOES. 

If fractures of the other bones of the feet are generally of such a 
character as to require immediate amputation, these fractures demand 
this extreme resort still more often. Our experience, therefore, in the 
treatment of fractures of the phalanges of the toes is extremely limited. 

Lonsdale observes that it is not uncommon to find great irritation arise after 
fracture of the great toe ; an inflammation extending along the absorbents on 
the inside of the leg to the groin, causing abscesses to form in different parts of 
the limb, and producing sometimes great constitutional disturbance. An illus- 
trative case has come under my own observation. The patient, M. McM., set. 
18, several days before received an injury upon the great toe, which contused 
the flesh severely and broke the first phalanx. He was then suffering from 
severe pain in the foot and leg, and the absorbents were inflamed quite to the 
groin. Poultices being applied to the foot and cool lotions to the limb, the in- 
flammation soon subsided, but not until a portion of the toe had sloughed away. 
Eventually also it became necessary to remove some portion of the phalanx, 
which had died; after which the wounds healed kindly. 

When any of the smaller toes are broken, it will be found easier to 
support the fragments by a broad and long splint which shall cover the 
whole sole of the foot and all the toes at the same time, than to attempt 
to apply a splint to the broken toe alone. If, however, we prefer this 
latter mode, a thin piece of gutta-percha will be found altogether the 
most convenient material for the purpose. 

If the great toe is broken, its great breadth may prevent any displace- 
ment, and a well-moulded gutta-percha splint will generally secure a 
perfect and rapid union. 



CHAPTER XXXVII. 

GUNSHOT FRACTURES. 

Gunshot fractures have already been considered, more or less in de- 
tail, in the several portions of this work, wherever it seemed to be neces- 
sary to call especial attention to them. This chapter will be devoted, 
therefore, to a brief resume of my own observations and conclusions in 
this department. 

Causes. — Gunshot fractures are caused by a great variety of missiles, 
such as musket- and rifle- balls, solid shot and shell, grape, canister, 
Shrapnel, chain- and bar-shot, fragments of iron, stone, splinters of wood, 



GUNSHOT FRACTURES. 499 

etc., etc. The only qualities which these missiles possess in common is, 
that they are all projected by the elastic power of gunpowder, and gener- 
ally strike the body with great force ; and that they cause fractures by 
direct violence — seldom, if ever, by counter-stroke. Round, smooth 
balls frequently impinge upon bones without causing a fracture, for the 
reason that they are easily deflected ; and this happens especially when 
they are not moving with great velocity. Conical rifle-balls seldom fail 
to fracture the bones which lie in their direct course ; never, perhaps, 
when, at the moment of contact, the ball is moving with its average 
velocity. The peculiar destructiveness of this missile is due to its weight, 
momentum, and form. Canister, grape, Shrapnel, solid shot, shells, and 
chain- and bar-shot are still more destructive ; generally tearing the 
limbs from the body in such a manner as to render readjustment and 
restoration impossible. 

Pathology. — These fractures may be simple, compound, comminuted, 
or complicated ; and in addition to these common varieties of fractures 
there is occasionally presented an example of simple "perforation," or 
mere penetration of the bone without fissure or other fracture ; and still 
more frequently are seen examples of perforation with fissures. 

Probably ninety-nine per cent, of all gunshot fractures are both compound 
and comminuted ; the comminution being, in general, excessive. 

As in gunshot wounds of the soft parts it has been generally observed 
that the point of entrance is more round, more smooth, and somewhat 
smaller than the point of exit, and that the tissues are a little depressed 
at the entrance, while they are slightly protruded at the exit ; so also in 
gunshot fractures it will often be found that the side of the bone on which 
the ball has entered, or upon which it first impinged, is less comminuted 
than the opposite side; and, if it is a "perforation," that the opening is 
smaller upon the one side than upon the other ; that the edges are slightly 
depressed upon one side, and elevated or protruded upon the other ; and, 
finally, that numerous small, as well as some large, fragments of bone 
have been carried into that portion of the track of the wound which lies 
between the bone and the point of exit of the missile. When a ball 
fractures the shaft of a long bone, although the blow may have been 
received three, four, or even six inches from an articulation, the com- 
minution or a single longitudinal fissure may sometimes be found extend- 
ing into the joint. These fissures or splittings of the shaft often extend 
also a long distance up or down, without terminating in the joint. 

Perforations without fissure occur most often in the broad bones of the 
pelvis, in the scapula, or in the spongy extremities of the long bones. 
In the latter, however, it is exceedingly rare to find perforation without 
fissure. Perforations with fissure are pretty common in the head of the 
humerus and in the head of the tibia ; they occur also, but less often, in 
the lower ends of the femur and tibia, in the trochanteric portion of the 
femur, and in the head of the femur. 

I wish to be understood to say that fissures occur less often at the points last 
mentioned, simply because perforations are there less common. It should be 
known that if perforations do occur at these points, a splitting or fissure com- 



500 GUNSHOT FRACTURES. 

municating with the joints is almost inevitable. A misunderstanding here would 
lead to a very fatal error in many cases. 

Prognosis.— In general it may be stated that gunshot fractures of the 
upper extremities do not demand amputation, and that similar injuries in 
the lower extremities do demand amputation. 

This statement is very broad, and cannot be understood except by a 
consideration of these accidents somewhat in detail. It may be stated 
that gunshot fractures of the clavicle, scapula, of the shaft of the humerus, 
of the shafts of the radius and ulna, and of the carpal, metacarpal, and 
phalangeal bones, notwithstanding these bones have suffered extensive 
comminution, do not usually demand amputation ; they will in most cases 
eventually unite, and give to the patients tolerably useful limbs. If, 
however, at the same time that the shaft of the humerus, or of the radius 
and ulna, is thus broken, the large nervous trunks are torn asunder, so 
that the extremity is cold and insensible, the limb cannot probably be 
saved, nor, if it could be, would it be of any value. Destruction of the 
main artery supplying the limb diminishes the chance of its being saved, 
but does not, in the case of the upper extremities, necessarily demand 
amputation. Penetration of the shoulder-joint by a musket- or rifle-ball, 
producing a fracture of the head of the humerus or of the glenoid cavity 
of the scapula, demands amputation w T hen either the axillary artery or 
axillary nerves are injured ; but resection can generally be practised 
with a reasonable chance of success when the arteries and nerves are 
untouched. Resection is also made successfully at the shoulder-joint in 
some cases where larger missiles have traversed the joint, such as canister, 
fragments of shell, etc. 

Penetration of the elbow-joint by a large shot, or by a Minie rifle-ball, 
the missile fairly entering or traversing the joint, demands amputation 
when the main arterial and nervous supplies are cut off, and resection, 
generally, when both remain uninjured. Resection may be attempted at 
the elbow-joint, also in some cases where, the nervous supply remaining 
good, only one of the principal arterial trunks is cut off. Frequently a 
ball strikes the outer or inner condyle of the humerus, making but a 
small opening into the joint, and producing only slight comminution, and 
in such cases we often save the limb with more or less ankylosis, and 
without resection. The remarks which have been made in reference to 
gunshot fractures of the elbow-joint apply, almost without qualification, 
to the same accidents at the wrist-joint. For gunshot wounds with frac- 
ture of the carpal, metacarpal, and phalangeal bones neither resection 
nor amputation is often required, unless the soft parts are almost com- 
pletely torn away. 

The prognosis which, as we have now seen, is so favorable in the upper 
extremities, will be found very different in the lower extremities; indeed, 
it is almost reversed. Thus : Gunshot fractures of the shaft of the thigh, 
of the shafts of the tibia and fibula, and of the tarsal bones, generally 
demand amputation ; or, to be more precise, gunshot fractures of the 
head and neck of the femur almost always terminate fatally under ampu- 
tation or excision, and equally under treatment as fractures, that is, 
where an attempt is made to save the limb, without interference with 



GUNSHOT FRACTURES 



501 



the knife. The same accidents in the upper third of the shaft of the 
femur are generally fatal ; but if the main artery and the principal nerves 
are uninjured, the life is, in general, less hazarded by an attempt to save 
the limb than by amputation. In the middle third, under the same cir- 
cumstances, the chances may be considered equal, as between amputation 
and the attempt to save the limb by apparatus ; in the lower third the 
chances are in favor of amputation. 



Fig 



Fig. 332. 




Gunshot fracture of thigh. (Author's collection.) 
Side view. Front view. 



The above statements in relation to fractures of the femur are based mainly 
upon my own experience, and have been carefully considered. I have seen no 
resections of the knee-joint, and but few of the shaft of the femur, after gunshot 
fractures, which have not terminated fatally. 

[These opinions belong to the period antedating the use of antiseptics and 
were undoubtedly correct. But the surgeon can now prevent suppuration, and 
this fact should determine the treatment of each case.] 

Gunshot fractures of the shafts of both tibia and fibula demand ampu- 
tation where the comminution is extensive, or the pulsation of the pos- 
terior tibial artery is lost, or the foot is cold and insensible. It is not 
intended to say that some limbs thus situated have not been saved, but 
only that the attempt to save such limbs greatly endangers the life of 
the patient, while amputation at or below the knee is relatively safe. 



502 GUNSHOT FRACTURES. 

Amputation is the only safe expedient in deep penetrating wounds of 
the tarsal bones produced by missiles of the size of musket-balls or larger. 
The only exceptions, which can safely be made, are in cases where balls 
have opened partially and superficially these articulations. Resections 
at the ankle-joint are much more hazardous than amputations, and 
scarcely to be preferred, in army practice, to attempts to save the foot 
without surgical interference. 

Treatment. — While considering the prognosis in these accidents, I 
have necessarily spoken of the treatment in certain cases ; especially with 
a view to the propriety of amputation or resection. It remains only to 
speak briefly of the treatment of those cases in which we may attempt 
to save the limb without resection, properly so called; for we must not 
forget that pretty often we find it necessary to remove small, loose frag- 
ments of bone by the finger, or by the aid of the knife, or to resect sharp 
points with the saw or the bone-cutters, when we do not practise " resec- 
tion " in the sense in which this term is usually employed by surgical 
writers. 

I shall take the liberty, in this connection, of reproducing what I have 
written elsewhere in relation to . gunshot fractures, since it comprises 
nearly all that seems necessar}^ to be added upon this subject. 1 " If an 
attempt is made to save a limb badly lacerated and broken, certain con- 
ditions in the treatment are necessary to success. All projecting pieces 
of bone which cannot be easily replaced and are not firmly attached to 
the soft parts, must be at once cut or sawn away. All foreign sub- 
stances, such as fragments of balls or other missiles, pieces of cloth, wad- 
ding, dirt, etc., must be removed. Any portions of integument, fascia, 
or muscles, which are entangled in the wound, and prevent a thorough 
exploration, or may obstruct the free escape of blood or of matter, must 
be freely divided. Counter-openings must be made at once, or at an early 
period after the formation of matter, to insure its easy escape (and in 
certain cases a drainage-tube must be carried through both wounds). 
The limb must be placed in an easy position, and not confined by tight 
bandages or forcibly extended by apparatus. The inflammation must be 
controlled by constitutional and local means, and especially by the use 
of water lotions whenever their employment is practicable. 

[It should be stated in this connection that the value of antiseptics in the 
treatment of gunshot wounds cannot be over-estimated. Vast numbers of limbs 
suffering from gunshots can now be saved by the prompt and persistent use of 
antiseptic solutions. The following instructions of Dr. Charles Smart, Surgeon 
U. S. Army, 2 are pertinent : " A clean incised wound, the sides of which have 
been immediately approximated, punctured wounds by lance or bayonet, even 
gunshot penetrations, if they do not contain fragments of clothing, or other 
foreign matters, may be so free from the bacteria of putrefaction as to heal like 
an aseptically treated wound, provided that their subsequent treatment be thor- 
oughly antiseptic. The first care given to a wound of this character is to pre- 
serve it from the contact of investigating fingers or probes, lest it be converted 
from a surgically clean wound into one invaded by germs. . . . The hands 
of the operator and his assistants must be well washed in the antiseptic liquid ; 

1 Treatise on Military Surgery, by Frank Hastings Hamilton. 1 vol., 8vo. Published 
by Bailliere Brothers. New York, 1861. Also enlarged edition of same work in 1865. 

2 Handbook for the Hospital Corps of the U. S. Army. 



GUNSHOT FRACTURES. 



503 



instruments, ligatures, sutures, sponges, etc., must be immersed in it before being 
used, and all the dressings saturated with it." This method rigidly carried out 
in the treatment of gunshot fractures would prevent suppuration and practically 
reduce compound to simple fractures.] 



Fig. 333. 




■HI 



Author's movable canvas. 



;^ - : v :: ' 



If joints are implicated seriously, and an attempt is still made to save 
the limb, the joint-surfaces must be laid freely open, so as to prevent all 
possibility of the confinement of blood, serum, or pus; and the joint must 
be placed perfectly at rest, without adhesive strips, bandages, or any 
apparatus which shall compress the limb or embarrass its circulation. 

I still give the preference, in fractures of the femur, to the straight 
position. In most cases I have preferred my own apparatus, already 
described when speaking of fractures of the thigh in general, with 



Fig. 334. 




. JiJSi'lUill! 



Movable canvas, with extension, on " horses." 

moderate extension ; and by moderate extension is to be understood such 
as may be effected with from five to ten pounds. 

A movable canvas, such as is shown in the accompanying woodcuts 



504 



GUNSHOT FRACTURES. 



with a hole in the centre, and reinforced by an additional piece of canvas 
where the weight of the hips rests, will enable the surgeon to move his 
patient and clean the bed when necessary. The standard which supports 
the pulley can be received in a slot in the frame. 

An apparatus similar to this was used, during our late war, in the Lincoln 
General Hospital at Washington. I have also used, with the movable canvas, 
and upon an ordinary bed, Hodgen's apparatus, or '' cradle," as he terms it, and 
have found it exceedingly useful, and much preferable to any form of double 
inclined plane, whether suspended or not. The cradle is simply a skeleton-box, 
of the length of the thigh and leg, made of light strips of wood. Across the two 
upper bars are laid, transversely, cloth bands, upon which the limb is laid at 
full length. 1 

Of gunshot fractures of the femur many hundreds, probably many thousands, 
during and since the close of our civil war, have come under my observation ; 
but of these, only 92 have been made the subject of especial record. Of this 
number, 75 were fractures of the shaft of the femur ; 9 being fractures of the 
upper third; 36 of the middle third; and 30 of the lower third. Nearly all of 
these fractures were caused by the conical rifle-ball. They were treated in 
various Federal and Confederate hospitals by a great variety of methods, and 

Fig. 335. 




Fig. 336. 




Hodgen's apparatus for gunshot fractures of the thigh. 

under a variety of circumstances, which latter were sometimes favorable and 
sometimes unfavorable. The results may, therefore, be regarded as furnishing 
a fair basis for conclusions as to what may reasonably be expected in army sur- 
gery, or during the progress of a great war. I have a strong conviction, how- 
ever, that if in an equal number of cases the straight position, with moderate 
extension, were to be employed, and the circumstances were as favorable as are 
usually found in civil hospitals, the results would be considerably better than 
are here shown. Indeed, my own recorded cases show, in a marked degree, the 
advantages of the straight position, with slight extension, over the double 
inclined planes. In a number of these cases, while the limb was flexed, the 
shortening and bending were excessive, and the substitution of Buck's apparatus, 



1 Hodgen, Treatise on Military Surgery, by the author, p. 408. 



GUNSHOT FRACTURES. 505 

Hodgen's, or my own, has made at once a great improvement in both regards, 
besides contributing manifestly to the comfort of the patients. 

The average shortening, in those fractures of the shaft of the femur 
which were measured by myself after union was effected, was in the 
upper third, two inches and one eighth ; in the middle third, two inches 
and one-quarter ; and in the lower third, a little more than one inch and 
a half. In the upper third three were shortened two inches or more ; 
the greatest shortening being three inches and one-quarter. In the 
middle third, twenty were shortened two inches or more, six three inches 
or more, two four and a half, and one five inches. In the lower third, 
two were shortened two inches or more ; the greatest shortening being 
two inches and three-quarters. 

In a large proportion of the cases the thigh was bent at the point of fracture, 
the bend being in most cases outward, or to the fibular side of the limb. Where 
1ST. B,. Smith's suspension apparatus was used, the bend was usually backward, 
while in most of the cases treated in the straight position, with moderate exten- 
sion, the limb was nearly or quite straight. 

It is somewhat remarkable that in this table of ninety- two cases there are only 
three examples of union delayed beyond four months, and one of these patients 
was evidently about to die. In a pretty large proportion of cases the union was 
not delayed much beyond the usual period of union for a simple fracture, 
although the limb might be much shortened and crooked, and still discharging 
pus, with fragments of bone occasionally. 

Among the cases which have come under my especial notice the fol- 
lowing is of peculiar interest : 

President James A. Garfield was shot by the assassin Guiteau, July 2, 1881 , 
the weapon employed being a "bulldog" pistol of large size, which was fired at 
short range, the ball entering his body on the right side, about three and one- 
half inches from the spine. Its direction, after penetrating the muscular parietes, 
could not be determined. Immediately upon receipt of the injury he complained 
of sharp pains in his right foot and ankle, and later he felt similar pains in the 
left ankle, with slight pains in the right scrotum. These pains gradually subsided, 
and after a few days disappeared altogether. Beyond this there was never at 
any time a symptom pointing to an injury of the spine. No degree of paralysis 
ever ensued. President Garfield died September 19, 1881, eleven weeks after 
the receipt of his injury. The autopsy disclosed the following facts : 

The ball, after penetrating the thoracic wall at the tenth intercostal space, and 
fracturing the adjacent ribs, passed through the connective tissue and fat behind 
the upper edge of the right kidney, without wounding the liver, perforated the 
psoas fascia and the psoas magnus muscle near its attachment to the first lumbar 
vertebra, and penetrated the first lumbar vertebra in the upper part of the right 
side of its body. The aperture by which it entered the vertebra involved the 
intervertebral cartilage next above, and was situated just below and anterior to 
the intervertebral foramen, from which its upper margin was about one-quarter 
of an inch distant. Passing obliquely to the left and forward through the upper 
part of the body of the first lumbar vertebra, the bullet emerged by an aperture, 
the centre of which was about half an inch to the left of the median line, and 
which also involved the intervertebral cartilage next above. The cancellated 
tissue of the body of the first lumbar vertebra was very much comminuted and 
the fragments somewhat displaced. Several deep fissures extended from the 
track of the bullet into the lower part of the body of the twelfth dorsal vertebra. 
Others extended through the first lumbar vertebra into the intervertebral carti- 
lage between it and the second lumbar vertebra. Both this cartilage and that 
next above were partly destroyed by ulceration. A number of minute frag- 



506 



GUNSHOT FRACTURES. 



rnents from the fractured lumbar vertebra had been driven into the adjacent 
soft parts. 

It was further found that the right twelfth rib also was fractured at a point 
one inch and a quarter to the right of the transverse process of the twelfth 
dorsal vertebra ; this injury had not been recognized during life. 



Fig. 337. 




1st lumbar. 



2d lumbar. 



Course of the ball through the first lumbar vertebra, its direction being indicated by 

the probe. 

On sawing through the vertebra, a little to the right of the median line, it was 
found that the spinal canal was not involved by the track of the ball. The 
spinal cord and other contents of this portion of the spinal canal presented no 
abnormal appearances. The rest of the spinal cord was not examined. 

Fig. 338. 




Same specimen sawn open. 



Beyond the first lumbar vertebra the bullet continued to goto the left, passing 
behind the pancreas to the point where it was found. Here it was enveloped in 
a firm cyst of connective tissue, which contained besides the ball a minute quan- 



GUNSHOT FRACTURES. 507 

tity of inspissated, somewhat cheesy pus, which formed a thin layer over a por- 
tion of the surface of the lead. There was also a black shred adherent to a part 
of the cyst-wall, which proved on microscopical examination to be the remains 
of a blood-clot. For about an inch from this cyst the track of the ball behind 
the pancreas was completely obliterated by the healing process. Thence, as far 
backward as the body of the first lumbar vertebra, the track was filled with 
coagulated blood, which extended on the left into an irregular space rent in the 
adjoining adipose tissue behind the peritoneum and above the pancreas. The 
blood had worked its way to the left, bursting finally through the peritoneum 
behind the spleen into the abdominal cavity. The rending of the tissues by the 
extravasation of this blood was undoubtedly the cause of the paroxysms of pain 
which occurred a short time before death. 

The fatal hemorrhage proceeded from a rent nearly four-tenths of an inch 
long in the main trunk of the splenic artery, two inches and a half to the left of 
the coeliac axis. This rent must have occurred at least several days before death, 
since the everted edges in the slit in the vessel were united by firm adhesions to 
the surrounding connective tissue, thus forming an almost continuous wall 
bounding the adjoining portion of the blood-clot. Moreover, the peripheral 
portion of the clot in this vicinity was disposed in pretty firm concentric layers." 
It was further found that the cyst below the lower margin of the pancreas, in „ 
which the bullet was found, was situated three inches and a half to the left 
of the coeliac axis. 1 

1 See official report of the autopsy; made at Elberon, Long Branch, 1ST. J., September 20, 
1881, eighteen hours after death, by D. S. Lamb, of the Army Medical Museum, Acting Asst. 
Surgeon U. S. Army, in the presence of the attending physicians and surgeons— Joseph K. 
Barnes. Surgeon-General U. S. Army; J. J. Woodward, Surgeon U. S. Army; D. "W. Bliss, 
M.D. ; Robert Reyburn, M.D.; and of the consulting surgeons — Dr. Hayes Agnew, M.D , 
and Frank H. Hamilton, M.D. 

The report was signed also by Andrew H. Smith, M.D., who was present as a represent- 
ative of the coroner of the State of New Jersey. 

See, also, the author's summary of the President's case, Med. Gaz., Oct. 1881. 



PART II 



DISLOCATIONS 



DISLOCATIONS. 



CHAPTEK I. 

GENEEAL CONSIDERATIONS. 
§ 1. General Division and Nomenclature. 

A dislocation is the displacement of one bone from another bone or 
cartilage at the place of natural articulation. 

Dislocations may be divided into accidental or traumatic, spontaneous 
ov pathologic, and congenital. 

Our remarks upon the etiology, pathology, symptomatology, prognosis, 
and treatment of these injuries must be considered as applicable only to 
accidental or traumatic dislocations, unless the fact is in any case other- 
wise stated. 

Accidental dislocations are those in which the bones have suffered 
displacement in consequence of the application of a sudden force ; and 
surgeons have divided these accidents into Complete and Partial, Simple, 
Compound and Complicated, Recent and Ancient, Primitive and Con- 
secutive. 

A complete dislocation is one in which no portions of the articular 
surfaces remain in contact. 

A partial dislocation is one in which the articular surfaces are not 
completely removed from each other. 

A simple dislocation is that form of the accident in which the bone has 
only slid from its articulation, and is accompanied with the least or only 
an average amount of injury to the soft parts or to the bones adjacent to 
the joint. 

A compound dislocation implies that the articulating surface of the 
bone has been thrust through the flesh and skin ; or that in some other 
way a wound has been made which communicates with the joint. 

Complicated dislocation is a term employed by some writers to desig- 
nate a condition wholly differing from a compound dislocation, or, in some 
cases, a condition of extra complication. 

Thus, a simple dislocation may be complicated with a fracture, or with the 
laceration of an important bloodvessel, etc. ; and a compound dislocation may 
be complicated in the same way, and with the addition, perhaps, of extensive 
laceration and destruction of integument, muscles, nerves, etc. 

A recent luxation has taken place within a period of a few days, or, 
at most, of a few weeks ; and an ancient luxation has existed during a 



512 



GENERAL CONSIDERATIONS. 



longer period. The exact point of time at which a dislocation shall be 
called recent or ancient is not fully determined by surgeons, and the 
application of these terms is therefore always somewhat arbitrary. 

A 'primitive luxation is a luxation in which the bone remains nearly 
or precisely in the position into which it was at first thrown ; while a 
secondary or consecutive luxation is one in which the bone has subse- 
quently, in consequence of the action of the muscles, or from unsuccessful 
efforts at reduction, or from some other cause, changed its position suffi- 
ciently to entitle the accident to a new designation. Thus a primitive 
dislocation upon the ischiatic notch may become a secondary dislocation 
upon the dorsum ilii, or the reverse. 

General Predisposing Causes. — According to Malgaigne, whose con- 
clusions are based upon an analysis of six hundred and forty -three cases, 
dislocations are very rare in infancy, only one having occurred under five 
years ; but the frequency increases gradually up to the fifteenth year, 
from this period more rapidly up to the sixty-fifth year, and from this 
time onward, again, dislocations become more rare. He has mentioned 
none after the ninetieth year ; and the period of greatest frequency is 
between the thirtieth and sixty-fifth year. To this middle period belong 
four hundred and seven of the whole number. 

Kronlein 1 from an analysis of 400 cases has constructed the following table : 



Articulations. 


1-10 yrs 


11-20. 


21-30. 


31-40. 


41-50. 


51-60. 


61-70. 


71-80. 


Hip . . . . 
Knee .... 

Foot .... 

Meta/tarso-phalangeal . 

Shoulder 

Elbow .... 

Hand .... 

Metacarpo-phalangeal 

Interphalangeal . 

Sterno-clavicular 

Aeromio-clavicular 

Lower jaw . 

Spine .... 




4 

31 

6 
1 

1 

1 


*3 

1 

2 
49 

"i 

"i 

i 

2 


2 

55 
15 

1 
4 
5 
2 

'4 


1 
1 

1 

45 

.! 

8 

1 

'2 
1 


48 
4 

1 
1 

4 

2 


2 
1 

2 

36 
3 

"3 

1 


1 

i 

19 

1 
1 


2 
1 


Totals . 




44 


-69 


88 


65 


60 


48 


23 


3 



The inference from these analyses may be thus briefly stated : Age, as 
a general predisposing cause, is most active in middle life, and least 
active in advanced and in early life. 

It is proper, however, to observe that while such statistics may be relied upon 
as indicating the relative frequency of these accidents at different periods of life, 
they cannot be regarded as determining absolutely the value of age alone as a 
predisposing cause, since the direct or exciting causes may be more active at 
one period than another, and in some measure these latter causes may be, and 
doubtless are, responsible for such results. 



Kronlein, Luxationen, Deustche Chir. Von Billroth u. Luecke, 1882, p. 5. 



GENERAL DIVISION AND NOMENCLATURE. 513 

It may be stated as a general fact that persons of feeble constitution, 
and whose muscular systems are much weakened, suffer dislocation from 
slighter causes than those who are in health, and whose muscular systems 
are firm and vigorous; and that a relaxation of the ligaments which sur- 
round a joint, however this may have been occasioned, predisposes to 
dislocation. Thus, a paralyzed and atrophied limb is predisposed to 
luxation ; a joint in which the capsule has become stretched by effusions, 
or by violent extension, or weakened by laceration from a previous dis- 
location, or by ulceration — or if in any other way the articulation is de- 
prived of these natural protections, we need scarcely say, it is thereby 
rendered more liable to luxation. 

Ball-and-socket joints, other things being equal, are more liable to displace- 
ment than ginglymoid ; but then much more depends upon the relative exposure 
of the joint than upon its anatomical structure, so that the elbow is much more 
frequently dislocated than the hip ; the shoulder-joint, however, being, from its 
position and extent of motion, peculiarly exposed, and being also a ball-and- 
socket joint, is, of all others, most liable to dislocation. 

Direct or Exciting Causes. — These may be classed under two general 
heads, namely, external violence and muscular contraction. The action 
of certain ligaments in determining the direction of some dislocations is 
also a direct cause, but only subsidiary to the other causes named. 

External violence operates either directly or indirectly. When a 
person falls upon the knee and dislocates the head of the femur, the force 
is said to have acted indirectly, and this is by far the most frequent mode 
of dislocation ; but when the blow is received upon the upper end of the 
humerus, and its head is sent into the axilla, it is said to have been dis- 
located by direct violence. 

Muscular action produces a dislocation slowly, as in some cases of chronic 
rheumatism, and then it is termed a spontaneous or pathologic dislocation ; or 
suddenly, as in the violent spasmodic contractions which accompany convul- 
sions ; or sometimes by the mere voluntary effort of the muscles ; and both of 
these are true accidental luxations. 

It is very probable that external force can seldom be regarded as the 
sole cause of a dislocation, but that, in a large majority of cases, muscu- 
lar action consenting with the shock, performs an important role in the 
history of the accident. The limb, being driven obliquely across its 
socket by the external violence, is seized by the stretched and excited 
muscles with such vigor as to contribute not a little to the unfortunate 
result. Thus it will be found that the same force which is adequate to 
the production of a dislocation in the living and healthy subject is wholly 
insufficient to accomplish the same in the dead; and a man who is fully 
intoxicated seldom suffers a dislocation. 

General Symptoms. — As fractures are characterized by preternatural 
mobility and crepitus, to which may.be generally added the circumstance 
that when reduced the fragments will not remain in place without exter- 
nal support ; so, on the other hand, dislocations are characterized by 
preternatural rigidity, an absence of crepitus, and by the fact that when 
reduced the bone does not generally require support to maintain it in 
position. These three are the usual, and they may be termed the com- 

33 



514 GENERAL CONSIDERATIONS. 

mon, signs of distinction between fractures and dislocations, but no one 
of them can be alone depended upon as positively diagnostic. Gener- 
ally, when a bone has been dislocated, we shall find the limb in a certain 
position, which is uniform for all dislocations of the same character, and 
almost immovably fixed ; but when the ligaments and muscles about the 
joint have been extensively torn, or the whole body is still suffering under 
the shock, or in any other circumstances where the power of the muscles 
is weakened, this rigidity may give place to extreme mobility. 

True crepitus does not exist without fracture, but it is not always 
present in fractures ; and there is often a sensation produced in the rub- 
bing and chafing of dislocated bones which very much resembles certain 
kinds of crepitus, and by the inexperienced has been often mistaken for 
it. I allude to the subdued rasping sound or sensation which is found 
generally on the second or third day, and sometimes earlier, and which 
is the result of fibrinous effusions, or, perhaps, in some instances, of the 
mere rubbing of firmly- com pressed ligamentous and cartilaginous sur- 
faces upon each other. The crepitus of a recent fracture can be scarcely 
confounded with this obscure sensation, unless it is in some cases of in- 
complete fracture, or of a fracture situated remote from the surface, as in 
the case of the hip ; but a fracture which is a few days old, whose sur- 
face has become softened by inflammation and more or less covered with 
lymph, when the rigidity is great, may sometimes deceive the most expe- 
rienced surgeon : so exactly will it be found to imitate the sensations 
produced by the chafing of an inflamed joint, or of closely approximated 
fibrous surfaces. 

I have said that a true crepitus does not exist without a fracture ; but then a 
very minute fracture, such as the detachment of a scale of bone by the tearing 
away of a tendon or of a ligament, may produce crepitus ; or even the separation 
of a piece of cartilage may sufficiently expose the bone to determine the presence 
of this phenomenon. These are, however, no longer examples of simple disloca- 
tion. Nor are the two inverse propositions, in relation to the retention of the 
bones in place, invariable in their application. A broken bone, well reduced, 
does not always manifest a tendency to displacement ; nor does a dislocated 
limb, when restored to its socket, in all cases maintain its position, without 
support. 

The other general signs of dislocation are pain, swelling, and discolor- 
ation. The pain is generally more intense in dislocations than in frac- 
tures, the expanded end of the bone resting often upon one or more large 
nerves, which usually, with the arteries, approach very near the joints ; 
this pressure being also greatly increased by the extreme tension of the 
muscles. Not unfrequently numbness and temporary paralysis of the 
whole limb are the consequences. In other cases the pain is due solely 
to the pressure upon the muscles or to the tension of the muscles, or, 
perhaps, to the tension of the untorn ligaments and capsule. 

Generally the limb is shortened, but in a few cases it is found slightly length- 
ened, while the natural axis of the bone with its socket is always changed. If 
examined early, and before the supervention of swelling, the joint end of the dis- 
placed bone may be felt in its unnatural position, and a corresponding depres- 
sion may be discovered in the situation of the articulation, especially if the bones 
are superficial. 



GENERAL DIVISION AND NOMENCLATURE. 515 

Pathology. — The dissection of recent dislocations produced by external 
violence, shows the capsular ligaments more or less torn, and also a rup- 
ture of some of the lateral and other short ligaments, with a complete 
rupture in most cases of some of the tendons which immediately surround 
the joint, or of those which are attached to the capsule : the muscles, 
nerves, arteries, etc., through which the bone in its passage has passed, 
or upon which it is found resting, being also contused, stretched, or torn 
asunder. 

This description, however, does not apply to dislocations produced by mus- 
cular action alone, in a majority of which cases the capsule is only stretched, 
and not torn, and no lesions of other structures are necessarily present. 

If the dislocation remains unreduced, the margins of the old socket, in 
the cases of enarthrodial articulations, become gradually depressed, while 
the concavity of the socket is filling in with a fibrous or bony tissue, until 
at length the whole of this portion of the joint apparatus is nearly or 
entirely obliterated. This process is generally very slow, and may not 
be consummated until after the lapse of many years. At the same time, 
but with much greater rapidity, the head of the bone in its new position, 
and the soft or hard parts upon which it rests, are undergoing certain 
changes to adapt them to their new relations, and calculated in some 
measure to restore the limb to its normal functions. If the head of the 
bone rests upon muscle, the cellular and fibrous tissues which enter into 
the composition of the muscle become condensed and thickened, forming 
a shallow or elongated cup, whose margins are attached to the neck, or 
shaft of the bone, and whose walls are lubricated with synovia. If it 
rests upon bone, by a process of interstitial absorption a true socket is 
formed, sometimes deep and sometimes shallow, whose edges, receiving 
additional ossific depositions, become lifted so as to form a rim. At the 
same time the head of the bone is undergoing corresponding changes, to 
adapt itself to the newly-formed socket ; it is flattened or otherwise 
changed in form, and in the progress of this change its natural secreting 
and cartilaginous surfaces are gradually removed, a porcelaneous deposit 
taking its place. The same kind of hard, polished, ivory-like deposit is 
found also in those portions of the new socket which have been especially 
exposed to pressure and friction. Instead of the eburnation, an imper- 
fect fibro-serous surface or synovial capsule may be formed. 

I have in my cabinet an example of ancient luxation of the hip-joint in which 
the head of the femur, having rested upon the dorsum ilii, has formed a nearly 
flat but smooth surface — a kind of elevated plateau ; in other cases I have seen 
the margins of the new socket so elevated as to rest against the neck of the 
femur, and completely lock it in. 

Coincident with these changes, and in consequence partly of the disuse 
of the limb, the muscle, and even the bones sometimes suffer a gradual 
atrophy. In some measure these alterations may be due also to the 
pressure of the dislocated bone upon arterial and nervous trunks, by 
which their functions become partially or completely annihilated, and 
their structure even may be wholly obliterated. In consequence also of 
the inflammation whieh immediately results, we ought not to omit to 



516 GENERAL CONSIDERATIONS. 

notice that the trunk of a large artery sometimes becomes firmly adherent 
to the capsule or periosteum of a displaced bone, and its reduction is 
attended with imminent danger of laceration and of a fatal hemorrhage. 
Numerous instances of this grave accident, especially in attempts to reduce 
old dislocations of the shoulder-joint, are upon record. 

General Prognosis. — We shall study the prognosis of these accidents 
to better advantage when we come to speak of the individual bones and 
their various forms of dislocation ; but it is proper to state in this place, 
generally, that very few joints, having been once completely displaced 
from their sockets by external violence, are ever so completely restored 
as not to leave some traces of the accident, for many years, if not for the 
whole of the subsequent life of the patient, either in the partial limitation 
of their motions, or in the diminished size and power of the muscles of 
the limbs, or in the presence of an occasional arthritic pain : the degree 
and permanence of these sequences depending upon the joint which is 
the subject of the displacement, the extent of the original injury, the 
length of time it has remained unreduced, the means employed in its 
reduction, the health and condition of the patient, with so many other 
contingent circumstances as to preclude the idea of a complete specifica- 
tion. If the bone is not reduced, a permanent maiming is inevitable ; 
but it is surprising how much time and the intelligent processes of nature 
can eventually accomplish toward a restoration of the natural functions, 
especially when aided by a good constitution and judicious treatment. 
If the symmetry of form and grace of motion are never replaced, the 
value of the limb, for all the practical purposes of life, is not unfrequently 
completely reestablished. 

General Treatment. — The first indication of treatment is to reduce the 
bone. Whatever delays may be proper or justifiable in certain cases of 
fracture, such delays are never to be argued in cases of dislocation. The 
sooner the reduction is accomplished the better. For this purpose we 
resort at once to such manipulations or mechanical contrivances as the 
nature of the case demands ; and if these fail, or if at the first they are 
deemed insufficient, we invoke the aid of constitutional means, or such as 
are calculated to diminish the power and antagonism of the muscles. 
Many dislocations may be reduced promptly by manipulation alone; 
which mode is always to be preferred when it will prove sufficient, for 
the reasons that it is generally the least painful to the patient, and the 
least apt to inflict additional injury upon the muscles and ligaments. 

A person wholly unacquainted with anatomy or surgery may occasionally 
succeed in reducing a dislocated limb ; indeed, it frequently happens that the 
patient himself, by mere accident in getting up or in lying down, accomplishes 
the reduction ; and even in a very large majority of cases, force and perseverance 
will finally succeed by whomsoever they may be employed; but the observing 
student of surgery will soon discover the difference between accident and brute 
force on the one hand, and intelligent manipulation on the other. The char- 
latan bone-setter does not often allow himself to fail, unless the courage of his 
patient gives out, or he ignorantly supposes the reduction to be effected when it 
is not ; but his success, achieved through great and unnecessary suffering, is 
often obtained, also, at the expense of the limb; while the surgeon, whose 
knowledge of anatomy enables him to understand in what direction the muscles 
are offering resistance, and through what ligaments the head of the bone must 
be guided, lifts the limb gently in his hands, and the bone seeks its socket 



GENERAL DIVISION AND NOMENCLATURE. 



517 



promptly and without disturbance, as if it needed only the opportunity that it 
might demonstrate its willingness to return. 

We must understand not only what muscles and ligaments antagonize 
the reduction, if we would be most successful, but also what muscles, by 
being provoked to contraction, will themselves aid in the reduction. In 
short, to become expert bone-setters in the department of dislocations, 
one must possess a complete knowledge of the physiognomy or the 
external aspect of joints, acquired only by repeated and careful examina- 
tions, he must be familiar with the anatomy and functions of the muscles, 
he must understand thoroughly the ligaments, he must have experience, 
tact, and fertility of resource. 

Without these qualifications a man will do better never to undertake to treat 
dislocations, since he is constantly liable to mistake fractures for dislocations, 
and dislocations for fractures ; he will submit a sprained wrist to violent exten- 
sion, under the conviction that the joint is displaced ; he will mistake natural 
projections for deformities, and fail to recognize the real deformity when it actu- 
ally exists ; he will leave bones unreduced, fully believing that they are reduced ; 
and he will, all in all, within a few years, accomplish vastly more evil than he 
can ever do good. Let a man practise any other branch of surgery if he will, 
without experience or scientific knowledge, but he must not attempt to reduce 
dislocated bones. The most learned and the most skilful we shall find falling 
into error, embarrassed by the uncertainty of the diagnosis, or successfully re- 
sisted by the power of the opposing agents. What, 
then, can be expected of those who are both ignorant Fig. 339. 

and inexperienced but failures and disasters ? 

As a means of disarming the muscles, or of 
placing them off their guard, we often practise 
successfully the diversion of the mind of the 
patient. At the very moment that the limb is 
moved or extension is made, a question is ad- 
dressed to him, or he may be suddenly surprised 
by some unexpected intelligence. 

Extension and counter-extension, made 
with our own hands or with the hands of 
assistants, constitute the second resort where 
manipulation alone has failed. The surgeon, 
seizing upon the limb firmly with his hands, 
makes the extension, while the assistants 
make the counter-extension ; or, instead of 
grasping the limb directly, the operator may 
use for this purpose circular and longitudinal 
bandages, or the bandage or handkerchief tied 
in the form of the clove-hitch. Extension is 
thus applied in connection with manipulation, 
aided, perhaps, by direct pressure upon the 
head of the displaced bone. Failing in this, we employ some one of the 
various mechanical contrivances which, while they are capable of exerting 
much more power, possess also the important advantage of operating 
gradually and steadily, by which mode the resistance of the muscles is 
always more speedily and more completely overcome. 




Clove-hitch. (FroinEriehsen.) 



518 



GENERAL CONSIDERATIONS. 



For this purpose, Legros and Anger 1 have proposed the use of India-rubber 
tubes, to the number of five or six, extended gradually and successively to a 
proper tension, and maintained in this degree of tension for twenty or thirty 
minutes ; and others have advised the use of the pulley and weights, the latter of 
which methods I have often employed myself; but surgeons employ generally, in 
the case of the large limbs, the compound pulleys, or the simple rope windlass, 
which is thus described by Dr. Gilbert, of Philadelphia: " Place the patient, and 
adjust the extending and counter-extending bands as for pulleys ; then procure 
an ordinary bed-cord or a wash-line, tie the ends together, and again double it 
upon itself, pass it through the extending tapes or towels, doubling the whole 
once more, and fasten the distal end, consisting of four loops of rope, to a 
window-sill, door-sill, or staple, so that the cords are drawn moderately tight ; 
finally, pass a stick through the centre of the double rope, then by revolving 
the stick as an axis or double lever, the power is produced precisely as it should 
be in such cases, viz., slowly, steadily, and continuously." Jarvis's adjuster, 
although very complex, possesses some advantages over the pulleys, which may, 
perhaps, entitle it to the preference in a few cases. 

Fig. 340. 





Compound pulleys, and ring to which one end of the pulley-rope is fastened. 

Sedillot, 2 recognizing the danger of over-extension in the employment of me- 
chanical apparatus, and especially in the employment of the pulleys, conceived 
the idea of attaching to the latter a dynamometer, by which the exact amount of 
force applied could be determined. It is not, however, by any means certain 
that the dangers would be lessened by this means, since the amount of force 
which can safely be employed is seldom the same in any two cases which may 
be presented ; but, depending, as it must, upon the limb to which the traction is 
applied, its muscular power or resistance, the age, sex, and general condition of 
the patient, it is apparent that the limits of safety must be determined by the 
constant and careful observation of the limb while the extension is being 
applied, and, in short, by the judgment of the surgeon rather than by any fixed 
dynamic rule. 

Among the constitutional means, ether and chloroform occupy the first 
rank ; indeed, they are, at the present day, almost the only means of this 
class to which surgeons resort, and their value in this point of view can 
scarcely be over-estimated. Only when some unusual circumstance or 
condition of the patient forbade the use of an anaesthetic, would the 
surgeon return to the ancient practice of bleeding ad deliquiwn, of 
prostrating the system with antimony, or to the use of those vastly less 
efficient agents, opium and the warm bath. 



1 Legros and Anger, Arch. Gen. de Med., 1867. 

2 Sedillot et Gross, Art. Luxations, Die. Encyc. Sci. Med., Ser. 2d, t. iii. p. 295. 



DOUBLE OR BILATERAL DISLOCATION FORWARD. 519 



CHAPTEE II. 

DISLOCATIONS OF THE LOWER JAW (TEMPOKO-MAXILLARY). 

There are two principal forms of this dislocation, namely, the double 
or bilateral dislocation, and the single or unilateral ; in both of which 
the direction of the displacement is forward. To these there may be 
added as having been occasionally observed an outward displacement 
accompanied with a fracture, and occasionally a backward dislocation, 
with fracture of the meatus auditorius externus. 

In order that we may better understand the pathology of this aceident, it will 
be proper to say a few words in relation to the anatomy of the temporo-maxillary 
articulation and the other parts concerned in the dislocation now under con- 
sideration. The articulation is formed by the condyloid process of the inferior 
maxilla and the glenoid fossa of the temporal bone, in front of which fossa, and 
at the root of the zygomatic arch, is a slight elevation, called the articular emi- 
nence. Between the joint surfaces, both of which are covered with cartilage of 
incrustation, is placed an interarticular cartilage, which divides the joint into 
two cavities, one corresponding to the condyle of the inferior maxilla, and the 
other to the glenoid fossa, each of which is furnished with a distinct synovial 
membrane. Properly there is but one ligament — namely, the external lateral — 
which passes from the outer surface of the articular eminence to the correspond- 
ing surface of the neck of the condyle. What is called the internal lateral 
ligament arises from the apex of the spinous process of the sphenoid bone, and 
is inserted into the margin of the dental foramen, and has therefore no imme- 
diate connection with the articulation, although it tends to strengthen the joint. 
The same is true of the stylo-maxillary ligaments. The lower jaw is drawn 
upward, or closed upon the upper jaw, by the action of the temporal, masseter, 
and internal pterygoid muscles ; it is drawn downward by the action of the 
digastricus, mylo-hyoideus, and genio-hyoglossus muscles ; forward by a few 
fibres of the masseter and by the external pterygoid muscles ; and laterally by 
the alternate action of the external and internal pterygoid muscles. When the 
mouth is open to its utmost extent, the maxillary condyle rises upon the articular 
eminence until it rests upon its very summit. Indeed, it is probable that in 
most persons it advances rather in front of the centre of the eminence ; so that 
in order to become actually dislocated it only needs that the capsule shall be 
somewhat relaxed, or that it shall actually give way in front, when the condyles 
slide forward and occupy a position directly in front instead of behind this 
eminence. 

§ 1. Double or Bilateral Dislocation Forward. 

This form of dislocation of the lower jaw is much the most frequent, 
being met with in about two out of every three cases. It appears also 
to occur oftener in women than in men, and usually between the twentieth 
and thirtieth year of life. In infancy and extreme old age it is exceed- 
ingly rare. 

Sir Astley Cooper mentions a case in which, "two boys" being at play, one 
had an apple thrust into his mouth, producing a double dislocation ; and 
Nelaton saw the same accident in an old man of seventy-two years, who was 
toothless. 



520 



DISLOCATIONS OF THE LOWER JAW. 



Fig. 341. 



This comparative immunity in youth and old age has been ascribed 
to certain peculiarities in the form of the jaw at these periods of life. 
Nelaton attributes its more frequent occurrence in middle life to the 
great length and strong anterior inclination of the coronoid process. 

Pathology. — It is easy to comprehend how the combined action of the 
two external pterygoid muscles, with a portion of the fibres of the mas- 
seter, may alone produce the dislocation when the mouth is wide open, 
and especially when, in consequence of a slight blow upon the chin, the 
anterior portion of the capsule becomes lacerated ; for it must be noticed 
that the ascending ramus, with its prolonged condyloid process, consti- 
tutes a lever of the first kind, in which the temporal muscle, attached to 
the coronoid process, the masseter, and even the mastoid process, consti- 
tute the fulcrum, the anterior portion of the capsule the weight, and the 
force acting against the front of the chin the power. 

In this position of the condyle, drawn upward and forward by the 
action of the pterygoid and temporal muscles, the chin descends toward 

the neck, and the coronoid process 
rests against the back of the su- 
perior maxilla, or against the 
malar bone at the point of its 
junction with the upper maxillary. 
The temporal, masseter, and in- 
ternal pterygoid muscles are very 
much upon the stretch, if not 
more or less lacerated. 

In addition to the influence of 
muscular action and the hooking 
of the condyle upon the malar 
and maxillary bones in maintain- 
ing the dislocation after it has 
once taken place, and in offering 
an obstacle to its reduction, there 
is to be considered the occasional 
displacement of the intra-articular cartilages, as demonstrated by Demar- 
quay, Mathieu, and Perier. 

Cause. — In a majority of cases the direct or immediate cause has 
seemed to be muscular action alone. 

Malgaigne found this cause to prevail in twenty-five out of forty cases ; and 
of the twenty-five cases fifteen were occasioned by gaping, five by convulsions, 
four by vomiting, and one by rage. Dr. Physick, of Philadelphia, found both 
condyles dislocated in a woman in consequence of the violent gesticulation of 
her jaw while scolding her husband. But in a more remarkable case still, this 
surgeon found the jaw dislocated after recovery from a profuse salivation, and 
of the cause of which, or the time of its occurrence, the patient, a young girl, 
could give no account. Dr. Physick made several ineffectual attempts at reduc- 
tion, and only succeeded at last after he had made her completely intoxicated 
with ardent spirits. 1 Andrews found both condyles dislocated by a lobelia 
emetic. The patient had often taken these emetics before, and had frequently 




Double dislocation of the inferior maxilla, 
forward. 



Physick, Dorsey's Elements of Surgery, vol. i. p. 202. Philadelphia, 1813. 



DOUBLE OR BILATERAL DISLOCATION FORWARD. 521 

experienced a sensation " of catching '' at the joint, but the jaw had always until 
this time resumed its position spontaneously. 1 

Dr. H. A. Steen, of Minnesota, met with a bilateral dislocation caused also by 
vomiting. 2 Dr. Edwin Morris 3 has seen the same occur during sleep with a 
young lady who from infancy had been accustomed to suck her tongue. 

Among the causes from outward violence, the introduction of some 
foreign body into the mouth, and the extraction of teeth, occupy the 
most important place. In fifteen cases seven were from the former and 
six from the latter cause. 

Dr. A. W. Gilbert has related a case which came under his own observation, 
produced by a similar cause. During his apprenticeship he was requested to 
insert a set of teeth for a young man, and while opening his mouth to take an 
impression of his gums, he dislocated " both condyles forward, under the zygo- 
matic arches; " but so perfectly were the muscles relaxed, that he immediately 
reduced them, without the least difficulty, by placing his thumbs as far back as 
possible upon the molar teeth, depressing the back part of the jaw, and at the 
same moment elevating the chin. 4 Prof. James Webster, of Eochester, N. Y., 
dislocated the jaw of a lady while attempting to pry out a root of one of the 
molars. 

Symptoms. — The mouth is widely open and the jaw nearly immovable. 
It has been noticed generally that, by pressure, the chin may be slightly 

Fig. 342. 




Dislocated lower jaw. 



depressed, but that, owing probably to the pressure of the coronoid pro- 
cess against the body of the upper maxilla, or against the malar bone, it 



1 Andrews, Peninsular Journ. Med., vol. iii. p. 101, 1855. 

2 Steen, Virginia Med. Monthly, June, 1878, p. 220. 

3 Morris, Brit. Med. Journ., Aug. 31, 1872. 



Poinsot, op. cit., p. 743. 



522 



DISLOCATIONS OF THE LOWER JAW. 



is generally impossible to elevate the jaw in any degree whatever. The 
jaw is also slightly advanced ; a depression, covering a considerable space, 
exists between the auditory canal and the posterior margin of the con- 
dyle. A slight fulness is observed in the temporal fossa, and also upon 
the side of the cheek in the region of the masseter muscle. Ordinarily 
the patient suffers considerable pain, but not always, from the pressure 
of the condyles upon the branches of the temporal nerves. There is a 
constant flowing of the saliva from the mouth ; the patient is unable to 
articulate, and even deglutition is performed with great difficulty. 

Prognosis. — When the dislocation remains unreduced, the lower jaw 
gradually approximates the upper, and its anterior projection sensibly 
diminishes, the saliva ceases to dribble from the mouth, deglutition and 
speech are restored, mastication is performed with considerable ease, and, 
in short, the patient comes at length to experience no great inconvenience 
from the displacement. 

Robert Smith relates the case of a woman whose lower jaw was dislocated 
during an epileptic convulsion. She was at the time in one of the metropolitan 
hospitals, but the accident was not noticed by the surgeons, and it remained 
ever afterward unreduced. At the end of a year she could close the lips per- 
fectly, but was able to open the mouth only to a limited extent ; the teeth of 
the lower jaw remained advanced, the involuntary flow of saliva had ceased, 
and the faculty of speech had been regained. 1 In Professor Webster's case, to 
which I have before referred, although the jaw was immediately and easily re- 
duced, after the lapse of several years, when I saw the lady, she still complained 
that it hurt her whenever she ate, and that she often felt the condyles slip in 
their sockets. Reduction was accomplished by Physick in the case already re- 
lated, after the lapse of several weeks ; Sir Astley Cooper reduced a double dis- 
location after a month and five days, which had been overlooked by the surgeon 
in attendance ; 2 and Donovan succeeded after ninety-five days. 3 In two cases 
treated by Michon and Gosselin the reduction was effected at one hundred and 
thirty days. 4 

Treatment. — Reduction may generally be accomplished with ease in 
cases of recent dislocation, in the following manner : The patient being 
seated upon the floor with his head between the knees of the operator, a 



Fig. 34 




Method of reducing lower jaw. 



1 Robert Smith on Fractures and Dislocations, p. 288. Dublin, 1854. 

2 Sir Astley Cooper on Disloc. and Frac, Amer. ed., p. 316. 

3 Donovan, Amer. Journ. Med. Sci., Oct. 1842, p. 470 ; from Dublin Med. Press, May 25, 
1842. 

4 Poinsot, op. cit., p. 744. 






DOUBLE OR BILATERAL DISLOCATION FORWARD. 523 

couple of pieces of cork, gutta-percha, or pine wood are placed as far 
back between the molars as possible, when the surgeon seizing upon the 
chin draws it steadily upward, taking care not to draw it forward at the 
same time, since by this movement he would resist the action of the 
muscles which naturally tend to restore it to place whenever the condy- 
loid processes are lifted sufficiently from the zygomatic fossae. 

Many surgeons prefer to sit or stand in front of the patient, and depress the 
condyles by means of the thumbs placed inside of the mouth and upon the tops 
of the molars. If the thumbs are used in this way, it would be well to protect 
them with a piece of leather, or to slip them off from the teeth suddenly when 
the condyles are gliding into their places, as the muscles sometimes close the 
mouth with sufficient violence to bruise severely anything which might at that 
moment be interposed between the teeth. 

The method practised by Eavaton, of simply lifting the chin gradually and 
forcibly toward the upper jaw, was essentially the same, but far Jess efficient ; 
for, although he placed nothing between the molars to serve as a fulcrum, the 
backmost teeth-themselves must in some degree perform this service whenever, 
the lower jaw being dislocated and drawn upward, the chin is forcibly approxi- 
mated toward the upper. 

In other .cases it has been found necessary first to disengage the coro- 
noid process, by depressing the chin gently, and then pressing backward 
in the direction of the articulation ; a method which would certainly 
deserve a trial in case of the failure of that first described. This was 
the method practised by Hippocrates. Lateral pressure made directly 
upon the condyle may facilitate the reduction. A more effectual expe- 
dient, however, consists in reducing one side at a time ; taking good care 
always that the side first reduced is not redislocated while the attempt is 
being made to reduce the other, a thing which happened in one of the 
cases treated by Sir Astley Cooper, and has happened many times in the 
practice of other surgeons. 

Finally, if all other expedients fail, we ought not to hesitate to resort 
to anaesthetics, nor indeed could any objection exist to their employment 
at any period of the treatment, were it not that in a large majority ot 
cases the reduction is effected so easily and promptly as to render their 
employment wholly unnecessary. After the reduction is accomplished, 
it will be a matter of wise precaution to sustain the jaAV by a double- 
headed bandage passed under the chin, and secured upon the top of the 
head ; so as to prevent the mouth from being accidentally opened too 
far, especially during sleep, since experience has shown that a tendency 
to a reproduction of the dislocation remains for some time. It will be 
prudent to continue these measures of protection for at least one week ; 
after which the danger of ankylosis should be borne in mind, and the 
extent of passive motion should be gradually and cautiously increased. 

In illustration of this tendency to redislocation, Malgaigne refers to the case 
mentioned by Putegnat of a woman whose jaw for many years became dislocated 
at least once a month ; but she was always able to reduce it herself. 



524 DISLOCATIONS OF THE LOWER JAW. 



§ 2. Single or Unilateral Dislocations Forward. 

Causes.— The causes of this accident are in general the same as those 
which produce double dislocations, and it occurs most often in middle life. 

Tartra has seen one exceptional example in a child only fifteen months old, 
and Levison saw a case in an old man who had lost all his teeth. 1 

Symptoms. — The mouth is open, but not so widely as in double dislo- 
cation ; the jaw is nearly immovable ; the teeth are advanced ; the con- 
dyloid process can be felt in front of the articular eminence, leaving a 
depression in its natural situation, and the coronoid process is more 
prominent than in the bilateral dislocation. It will be remembered that 
we have already pointed out an important diagnostic mark between a 
fracture of the neck of the condyloid process and a dislocation of one 
condyle. In the latter the chin inclines to the opposite side, while in the 
former it falls toward the side upon which the accident has occurred. 

According to Hey, this lateral deviation of the chin is not always present in 
dislocations; and Robert Smith mentions one case in which the surgeon was 
misled by the circumstances so far as to attempt a reduction upon the left side 
when the dislocation was upon the right. 

Treatment. — The same rules of treatment for dislocations of both con- 
dyles will be applicable to the single dislocations, with only such modifi- 
cations as will be naturally suggested to the surgeon. 

In the case mentioned by Levison, the dislocation was constantly recurring 
upon the left side ; and it was especially liable to happen when just awakening 
from sleep. " He would then pull his jaw, press it backward, when, after about 
half an hour's work, bang it seemed to go, and all was right again." This old 
gentleman was finally relieved of these annoyances by a band fastened under the 
chin. In such a case, an apparatus constructed after the same plan as my lower 
jaw apparatus might perhaps serve a useful purpose. 



§ 3. Dislocations Outward, with Fracture. 

Robert 2 was the first to observe this fact. The dislocation (left side) 
occurred in a man whose face had been traversed by the wheel of a cart, 
and was accompanied with a fracture in front of the ascending branch of 
the jaw on the right side. The dislocated condyle projected outward 
and could be distinctly felt and seen under the skin. The chin was 
inclined to the same side. 

In 1879 Dr. Neis 3 observed a second example of this dislocation, which he 
describes as " outward and upward into the temporal cavity," unaccompanied 
with fracture of the jaw. The subject was a young man whose chin and occiput 
were pressed between two boats. Dr. Neis supposed a fracture of the glenoid 
cavity, but he was not able to establish it, 

1 Levison, Boston Med. and Surg. Journ., vol. xxxiv., 1846, p. 388, from London Lancet. 

2 Eobert, Journ. de Chir., 1844, p. 265. 

8 Neis, These de Paris, 1879, No. 252. (Poinsot.) 



DISLOCATIONS BACKWAKD WITH FEACTURE. 525 

§ 4. Dislocations Backward, with Fracture. 

According to the researches of Baudriinont, this accident had been 
described by Lanfranc, Guy de Chauliac, and Jean de Vigo, but not 
until recently had any Avell-authenticated examples been published. 
Indeed, Baudrimont alone has recorded an example of bilateral disloca- 
tion backward. In a case reported by Croker-King the dislocation was 
unilateral, and was reduced by a method similar to that employed by 
Baudrimont, but it was not followed by any accidents ; while Lefevre 
mentions a unilateral dislocation backward which resulted in a cerebral 
abscess and death about five months after the injury was received. The 
dislocation was not recognized until the autopsy was made. In all of 
these examples the condyle, which rests with its centre over the point 
where the bony portion of the external auditory canal joins the cartil- 
aginous portion, being thrust backward has broken the margin of the 
bony portion and displaced or torn the cartilaginous portion, but without 
rupture of the ligaments. 

Braudrimont, 1 of Bordeaux, relates the following case : '' September 25, 1879, 
M. M., a carman, aged 63, who had lost all the teeth of the upper jaw, and a 
number of the molars of the lower, fell violently on his chin, experiencing at 
the moment a violent pain in both ears, and when he arose he found himself 
unable to move his jaw. There was a wound on the chin, absolute deafness 
existed, accompanied with an otorrhoea which continued until the following 
day. He was on the same day admitted to the Hospital of St. Andre, Bordeaux. 
His mouth was half open, the chin receded behind the upper jaw, as determined 
by the position of the incisors, fifteen millimetres. The lips could be closed, 
but the jaws could not. The backward displacement of the lower jaw caused a 
flattening of the cheeks, and gave to the mouth a peculiar grimace. The pos- 
terior portion of the jaw touched the sterno-mastoid muscle. The condyle was 
absent from its socket. Both auditory canals were closed by hard antero-inferior 
projections, which obeyed the slight movements which alone could be given to 
the jaw. The reduction was immediately attempted as follows: "The patient 
is seated on a chair, his head slightly thrown back and held by an assistant. 
Both thumbs are with difficulty introduced on both sides between the jaws, 
which can only be done by exaggerating the backward rocking movement of the 
jaw ; the thumbs press, by their palmar surfaces, on the lower molars. The 
other fingers brought under the chin, seize the body of the jaw, in a firm grip, 
on both sid-es. I press progressively and very energetically downward at first, 
then downward and forward. A sudden disengagement of the right condyle, 
which regains its place, is at first obtained with comparative ease. The disloca- 
tion is now single. The chin is deviated to the left. The same attempt is then 
made on the left side, but I then experience far more difficulty; a considerable 
effort proves insufficient; but with the help of the fingers pressing upon the con- 
dyle which is disengaged, the jaw rotates on itself and seems to make the hand 
which accompanies it describe a large circle, and the condyle resumes its articu- 
lation with a noise heard at a distance. The last phase of the reduction seems 
very painful, and as soon as the condyle leaves the ear the blood begins to flow 
from the left side. The movements of the jaw are reestablished, and are not 
very painful. Deafness partially disappears. " Examination of the ears shows 
that the membrane of the tympanum is torn on the right side, and there are in 
both auditory canals wounds of the integuments in which the probe detected 
bony splinters. Different local accidents ensue; sero-sanguinolent, serous, and 
sero-purulent discharges take place ; also a swelling of the articular regions, 
and, later on, suppuration. The patient left the hospital in a good condition. 
Three months after there still remained some swelling, articular stiffness, and a 
certain degree of deafness." 

1 Baudrimont, Journ. de Med. de Bordeaux, 1882, 13, 20, 27 aout. (Poinsot.) 



526 DISLOCATIONS OF THE LOWER JAW. 



§ 5. Conditions of the Jaw simulating Dislocations. 

There is a condition of the temporo-maxillary articulation called by 
Sir Astley Cooper " subluxation of the jaw," in which it is assumed that 
the condyles slip before the anterior margins of the interarticular carti- 
lages, and thus for the time render the jaw immovable, No positive evi- 
dence, however, has ever been presented, either by Sir Astley or others, 
that any such derangement of the joint apparatus does actually take place, 
the opinion being based, not upon dissections, but only upon the symp- 
toms which are known to accompany the accident. It is quite probable 
that this explanation of the phenomenon in question is the true one, yet 
it is not impossible that, in some rare cases, it has no relation whatever 
to the interarticular cartilages, but that it indicates a true subluxation of 
the inferior maxilla upon the zygomatic eminences. 

Causes. — It occurs mostly in young people, and in those of a feeble or 
scrofulous diathesis. Relaxation of the capsule, ligaments, and muscles 
about the joint may, therefore, be regarded as the principal predisposing 
cause. The exciting causes are generally yawning, or biting upon some 
very hard substance. 

The symptoms are a sudden arrest of the motions of the jaw, with the 
mouth about half-open, the arrest of motion being accompanied or pre- 
ceded generally with a sensation of slipping in one of the articulations. 
The chin is slightly inclined to the opposite side. The condyle may be 
felt somewhat advanced in its socket, and while it remains in this position 
the patient experiences some pain. In most cases the condyle resumes 
its place spontaneously, or after a slight lateral motion of the jaw ; but 
at other times it requires some little manual force to replace it. 

I had, during several years of my early life, while pursuing my studies at 
college, experienced this accident many times. It was peculiarly prone to occur 
in the morning, and it became necessary that I should eat with some care at my 
first meal. Sometimes the locking of the jaw was upon the right and sometimes 
upon the left side ; it was always slightly painful. Generally the condyle was 
made to fall into place by a voluntary lateral motion of the jaw, but occasionally 
I was obliged to press gently against the chin with my hand. I never adopted 
any measures to remove the predisposition, but as I became older the annoyance 
gradually ceased. 

Benevoli, in a dissertation published at Florence, Italy, in the year 1847, 
describes another condition very analogous to this which we have now described, 
but which evidently depended upon a contraction of the muscles. A priest, 
having opened his mouth very widely in gaping, found himself unable to close 
it. A surgeon who was called diognosticated a dislocation of the jaw, and 
attempted to reduce it, but failing, Benevoli was called, who, observing " that 
the jaw was not absolutely immovable, that the articulations were not separated, 
and that the chin did not incline outward or toward the sternum," concluded 
that it was only a contraction of the depressing muscles. He therefore pre- 
scribed fomentations and oily unctions. The same night the temporal muscles 
had acquired the size of a couple of eggs, from contraction, but the next day the 
patient could shut his mouth, and by the following day the tumefaction of the 
temporal muscles had also disappeared, and the restoration of the functions of 
the mouth was complete. Malgaigne, to whom I am indebted for the above 
case, relates two others, one in the person of the surgeon Mothe, and the other 
in a young man who was suffering from paralysis and spasmodic contractions of 
the muscles. Mothe observes that it had occurred to him very often, and that 
it still continued to happen sometimes, and when he gaped pretty widely, the 



DISLOCATIONS OF THE HYOID BONE. 527 

geniohyoid and myelo-hyoid muscles contracted with so much force as to render 
it impossible for him to close his mouth ; these muscles being thus in a state 
of cramp, their bellies became hard under the chin, and so painful that he was 
obliged immediately to press upward against the under surface of the chin in 
order to oppose their action. This condition would last from one to three 
minutes, and was relieved, generally, by frictions made with the hand over the 
contracted muscles. Sometimes he actually believed that the lower jaw was 
dislocated, although the result always convinced him that if was not. 

Treatment. — In most or all of the cases of this peculiar derangement 
of the temporo-maxillary articulation, which have come under my notice, 
a spontaneous cure has been soon effected. It will be proper, however, 
in all cases, to instruct the patient to avoid using the jaw in a manner to 
produce the sensation of slipping ; and if the general health is impaired, 
to adopt suitable measures to improve his condition. Cold water affusions 
to the side of the face and jaw would seem also to be rational measures, 
and I have generally recommended their use. 



CHAPTEE III. 

DISLOCATIONS OF THE HYOID BOXE (THYRO-HYOID 
ARTICULATION). 

Dr. Ripley, of South Carolina, and Dr. Gibb, of London, have alone 
furnished us with examples of this accident, but as I am unable to con- 
sult the original communications of either of these gentlemen, I will take 
the liberty of reproducing a brief summary of their papers contained in 
Mr. Durham's contribution to Holmes's Surgery. 1 

'* Gibb 2 has recorded in the following words a case of dislocation of the hyoid 
bone in a patient under his care : ' The patient, a man, set. 45, would feel a 
sudden click in the left side of his neck, which produced a sensation as if some- 
thing was sticking in his throat. On examination, this appeared to me to depend 
upon a displacement of the left horn of the hyoid bone, and was generally 
reduced by throwing the head backward, toward the right side, so as to stretch 
the muscles of the neck, and then suddenly depressing the lower jaw, and so 
putting the depressors of the hyoid bone into operation. He died some years 
after of pulmonary consumption. On examining his throat after death, I found 
a sort of pouch, which answered the purpose of a synovial capsule, embracing the 
horns of the left thyro-hyoid articulation. It was filled with a clear fluid, had 
a comparatively large rhomboid sesamoid bone developed in its outer wall, and 
permitted an extraordinary amount of motion.' This was the fourth case of the 
kind which had come under the notice of Gibb. All the patients were males. 
He subsequently met with a fifth case in which the patient was a female. 

"Reference is made in the work quoted to a paper, read in 1848 before the 
Parisian Medical Society, by Dr. Ripley, of South Carolina, on ' Dislocations of 
the Os Hyoides, especially illustrated in his own person, and the manner of 
reducing them.' The latter process consisted in throwing the head backward 
as far as possible, so as to place the muscles of the neck on the stretch, then 

1 Holmes's Surgery, 2d Amer ed., vol. ii. p. 460. Art. Injuries of the Neck. 

2 Gibb, on Diseases and Injuries of the Hyoid Bone, by G-. D. Gibb, M.D., Churchill, 
London, 1862, p. 20, and Trans. Path. Soc, London, vol. x. p. 66. 



528 DISLOCATIONS OF THE SPINE. 

relaxing the lower jaw, at the same time gently pressing or rubbing over the 
displaced part, when the displacement becomes reduced after a few attempts 
with a click. Two cases of dysphagia described by Abercrombie are considered 
by Gibb to have been examples of double displacement of the thyro-hyoid 
articulation." 



CHAPTER IV. 

DISLOCATIONS OF THE SPINE. 

This accident is, no doubt, exceedingly rare, at least without the com- 
plication of a fracture, and it is not improbable that the actual number 
is smaller than the reported examples would indicate. Those who make 
autopsies do not always perform their duties with that exact fidelity 
which might be necessary to determine so nice a point as a fracture of 
an oblique process, and it is quite likely that the circumstance may have 
been overlooked in some cases ; but a considerable number of well- 
authenticated examples of simple dislocations of cervical vertebrae have 
accumulated within the last fifty years. The reported examples of 
simple dislocations of the other vertebrae are not so numerous, nor as 
well attested. 

Delpech and A.bernethy denied the possibility of a dislocation of the spine, 
either in the cervical, dorsal, or lumbar region, without the concurrence of a 
fracture. Says Sir Astley Cooper : " I have never witnessed a separation of one 
vertebra from another through the intervertebral substance, without fracture of 
the articular processes ; or, if those processes remain unbroken, without a frac- 
ture through the bodies of the vertebrae." He would not, however, be under- 
stood to deny the possibility of a dislocation of the cervical vertebrae, their 
articular processes being placed more obliquely than those of the other vertebrae. 

The causes are in general the same as those which produce fractures 
of the vertebrae, such as falls upon the head, feet, or back, and violent 
flexions of the spine backward or to the one side or the other. 

Several examples are recorded of "spontaneous" dislocations, the result of 
some morbid changes in the bones or in the ligaments of the spinal column ; 
which accidents seem to belong more properly to general treatises upon surgery. 

The symptoms, also, partake of the same general character with frac- 
tures; the accident being accompanied with more or less complete paral- 
ysis of those portions of the body which receive their nervous supply 
from below the point at which the dislocation has occurred ; the spinal 
column presenting at the seat of displacement an angular projection or 
some form of irregularity ; and the distortion being attended with pain, 
especially when an attempt is made to move the body. In very many 
cases the symptoms are so nearly like those presented in a case of frac- 
ture, that the diagnosis is rendered exceedingly difficult. The presence 
or absence of crepitus may aid in the diagnosis, and yet it is well under- 
stood that this symptom is often absent in simple fractures, and that it 






DISLOCATIONS OF THE LUMBAR VERTEBRJ. 529 

may be present in all those examples of dislocation which are accom- 
panied with a fracture of an oblique process, or of any other portion of 
the vertebrae, which class of examples constitutes a large majority of the 
whole number. 

There is usually present, however, in the dislocation, whether partial 
or complete, a peculiar fixedness or rigidity of the spine, which serves 
to distinguish this accident from a fracture of the spine as plainly as the 
preternatural rigidity of the limb in dislocations of the long bones serves 
to distinguish these accidents from fractures of the same bones. The 
head or upper portion of the spinal column is bent forward, or back- 
ward, or more commonly to one side, and in this position it remains 
immovably fixed until the reduction is accomplished. Sometimes, also, 
the surgeon may feel distinctly the lateral deviation of the spinous pro- 
cess, and, in the neck, the transverse processes become an important 
guide in the diagnosis. 

§ 1. Dislocations of the Lumbar Vertebrae. 

Without wishing to insist upon the actual impossibility of these acci- 
dents, I am prepared to affirm that no well-authenticated case has yet 
been reported — at least of a complete dislocation, unaccompanied with a 
fracture of the articulating apophyses. I can conceive it possible that 
a lumbar vertebra may be dislocated forward or backward, and that a 
dorsal vertebra may be dislocated laterally, without a fracture ; but 
neither of these events can be considered probable. It is certain, how- 
ever, that no evidence has yet been furnished of the actual occurrence of 
such a dislocation. 

Colquet mentions the case of a " tiler" who fell from the roof of a house back- 
ward, and dislocated one of the lumbar vertebrae. This patient lived many years 
after the accident, and at the autopsy it was found that the second lumbar ver- 
tebra had been dislocated to the right by a movement of rotation about the left 
articular process, the two oblique processes of the left side preserving their con- 
nection, while those of the right were separated quite half an inch. The right 
vertebral plate was broken, and the canal of the vertebra was thus thrown open 
and widened. 1 

Dupuytren says that a man was crushed by the falling of a bank of earth upon 
his loins, when in the act of bending forward. On the third day he was brought 
to Hotel Dieu, when it was observed that his lower extremities were completely 
paralyzed ; and that there existed in the upper part of the lumbar region a hard 
tumor, by pressure upon which a crepitus was manifest. A second tumor could 
be distinctly felt in front through the abdominal parietes, and the length of the 
spine was evidently diminished. This man died on the sixth day from a gradual 
asphyxia. When the body was examined it was found that the last dorsal and 
the first lumbar vertebras had been pushed forward more than one inch, lacerat- 
ing the spinal marrow, breaking the transverse and oblique processes of the last 
dorsal and first lumbar vertebras, and tearing off a small fragment of the body of 
one of the vertebras where the intervertebral substance adhered to it. 2 

Vincent 3 presented in 1850 to the Anatomical Society of Paris a complex dis- 
location of the first lumbar vertebra, with destruction of the extremity of the 
spinal marrow, and interruption of the nervous function of the cauda equina. 

1 Cloquet, Malgaigne, op. cit., t. ii. p. 390, from Journ. des Difformites, torn. i. p. 453. 

2 Dupuytren, Injuries and Diseases of Bones, Syd. ed., p. 340. 

3 Vincent, Bull. Soe. Anat., 1850 (Poinsot). 

34 



530 DISLOCATIONS OF THE SPINE. 

Despite the most complete paraplegia the fracture became consolidated, and the 
patient survived eight months. 

All of these cases were accompanied with fractures. In neither case was any 
attempt made to reduce the dislocation. In the second, it is scarcely probable 
that any means could have been employed which would have succeeded in 
restoring the bones to their places ; nor is it probable that, if the bones had been 
restored to place, the patient would have survived the accident a day longer, 
probably not so long. The cord was greatly lacerated, and the diaphragm torn 
up and displaced, rendering a recovery almost impossible. In the first example, 
where the dislocation was less complete, and the complications less grave, could 
reduction have offered any reasonable chance for relief? By extension, com- 
bined with a movement of rotation in a direction opposite to that in which the 
displacement had taken place, it is possible that a reduction might have been 
accomplished. The attempt certainly would have been justifiable; but since 
the man lived "many years" without the reduction, it is doubtful whether the 
result of a reduction would have been more fortunate. 

§ 2. Dislocations of the Dorsal Vertebrae. 

A moment's consideration of the anatomy of these processes will render 
it apparent that even a partial dislocation forward without a fracture of 
the oblique apophyses is impossible ; and that in the direction backward 
the dislocation can only occur to the extent of about one-quarter of an 
inch, constituting only a species of articular diastasis, without breaking 
off the articulating apophyses of the lower corresponding vertebra. 

Malgaigne enumerates twelve examples of dislocations of the dorsal vertebrae. 
I have found reported by American surgeons, at dates too recent to have been 
included in his analysis, two other examples. Poinsot has added three more 
cases, one reported by Thompson, of Dublin, 1 a second by Socin, of Bale, 2 and a 
third by himself. 3 In Thompson's case there was a complete dislocation of the 
twelfth dorsal upon the first lumbar, with fracture of the spinous process, accom- 
panied with rupture of the aorta and spinal cord. In Socin's case it was the 
eleventh and twelfth ; and in Poinsot's case there was dislocation forward of the 
twelfth dorsal upon the first lumbar. A portion of the anterior and superior 
border of the first lumbar was torn off; the left articular and right transverse 
processes were also broken. The patient survived the accident twenty-four days. 
I am unable to subject them to a more complete analysis. But of this number 
only three are claimed to have been simple dislocations, unaccompanied with 
fracture. One of the fourteen was a dislocation of the fifth dorsal vertebra upon 
the sixth, one of the eighth, two of the ninth, five of the eleventh, and five of 
the twelfth ; the relative frequency of their occurrence in the different vertebras 
corresponding with the observation of Weber as to the points of the spinal 
column which allow of the greatest freedom of motion, and are consequently 
most liable to dislocations. The direction of the displacement in ten cases was 
observed to be six times forward, twice backward, and twice to the one side. 
Two of those which were unaccompanied with fracture, occurring respectively 
in the tenth and sixth dorsal vertebras, were examples of a dislocation forward, 
and the third, belonging to the ninth vertebra, was a dislocation backward. A 
lateral dislocation without fracture has not been recorded. It is worthy of 
remark, also, that these three examples of uncomplicated dislocations, being all 
which our science up to this moment possesses, have happened in the experience 
of the same surgeon. 4 

The first two examples, therefore, notwithstanding they have been received 
without question by Malgaigne, I shall unhesitatingly reject. The third, which 

i Thompson, Dublin Journ. of Med. Sci., Oct. 1880. 

2 Socin, 1880. 3 Poinsot, op. cit., p. 754. 

4 Melchiori, Gaz. Medica Stati Sardi, 1850. 



DISLOCATIONS OF THE DORSAL VERTEBRAE. 531 

alone carries evidence of its having been correctly reported, and which was only 
a partial dislocation, is related as follows : " A mason having fallen from a height 
in such a manner that the lower part of his back struck upon the angle of the 
upper step of a ladder, died on the following day. After death it was observed 
that the spinous processes of the dorsal vertebras were prominent down to the 
tenth ; and that the tenth process with all of the processes below were depressed. 
It was also noticed that this depression, very marked when the trunk was thrown 
backward, gradually diminished, and finally disappeared altogether when the 
body was bent forward. On removing the soft parts it was found that the liga- 
ments were extensively torn asunder and detached, so as to permit the articu- 
lating apophyses of the tenth vertebra to be carried into contact with the back 
of the ninth. The spinal marrow had undergone no visible alteration." 1 

Malgaigne thinks he has once observed the same thing in a living sub- 
ject, and that by simply bending the body forward he accomplished the 
reduction and effected a perfect cure, except that a slight curvature 
remained at the point of injury. 

Among the cases reported as having been complicated with fracture, the fol- 
lowing example, reported by Dr. Graves, of New Hampshire, to Dr. Parker, of 
this city, possesses unusual interest : A man, set. 25 years, was struck on the 
back while in a stooping posture by a falling mass of timber, causing a disloca- 
tion of the last dorsal upon the first lumbar vertebra. His lower extremities 
were completely paralyzed, and priapism continued for several hours. The sur- 
geon determined to make an attempt at reduction, and for this purpose he placed 
the patient upon his face, and secured a folded sheet under his armpits and 
another around his hips, directing four strong men to make extension and coun- 
ter-extension by these sheets. Chloroform was administered, and when the 
patient was completely under its influence the extending and counter-extending 
forces were applied, and in a few minutes the vertebrae glided into place with a 
distinct bony crepitus. The restoration of the line of the vertebral column was 
found to be nearly but not quite perfect. On the sixteenth day he began to 
have slight sensation in his feet, and at the end of six or eight weeks he was 
able to control the evacuations from the bladder and rectum. Several months 
later he had recovered so completely as to walk with only the aid of a cane. 2 

I know of only one similar case. Rudiger has published an account of a dis- 
location obliquely backward and to the right side, which occurred at the same 
point in the spinal column. The subject was a musketeer, who had been struck 
upon his back by a falling wall which he was endeavoring to pull down. Ru- 
diger laid him upon his belly, and with the assistance of others he was able, but 
not without causing pain, to reduce the bones. Immediately, however, when 
the extension was discontinued, the action of the muscles caused the displace- 
ment to recur. The surgeon then directed four men to make extension, while 
another man retained the bones in place by pressing upon them with his hands. 
After several hours this method of pressure was replaced by a board underlaid 
with compresses and sustaining a weight of more than fifty livres. On the fol- 
lowing day it was found sufficient to bind compresses over the projecting bone, 
and in this condition the patient remained fifteen days ; during all of which 
time he lay upon his belly with his shoulders more elevated than his pelvis. On 
the twentieth day he could lie upon his back, and in about six weeks he was so 
completely restored as to be able to pursue his trade as before ! 3 This is certainly 
a very extraordinary case, whether considered in reference to the means em- 
ployed to restore the bones to place, or to its results ; and if the statements are 
to be received at all, it must be with some hesitation and allowance. 

On the other hand, we are able to present at least one example in which, 
although no reduction has been accomplished, the patient has survived the 
accident many years; yet it must be admitted that his recovery is far from 
having been as complete as in the two cases just mentioned. 

1 Melchiori, loc. cit. 2 Graves, New York Journ. Med., March, 1852, p. 190. 

3 Rudiger, Journ. de Chir.de Desault, torn. iii. p 59. 



532 DISLOCATIONS OF THE SPINE. 

J. S., set. 11 years, was crushed under the body of an ox-cart in such a manner 
as to produce a dislocation of the last dorsal from the first lumbar vertebra, 
causing immediately almost complete paralysis of all the parts below. This 
young man was seen by Dr. Swan, of Springfield, Mass., in the summer of 1834, 
at which time he was occupied as a portrait-painter. His lower extremities 
remained paralyzed, and of the same size as at the time of the receipt of the 
injury. He was unable to sit erect, owing to the mobility of the spine at the 
seat of dislocation, and he had, therefore, lain constantly upon his side. The 
upper portion of his body was well developed, and his intellectual faculties were 
of a high order. 1 A result so fortunate as this, where the bones remained unre- 
duced, is unique ; in all the other cases reported the patients died miserably 
after periods ranging from a few days to one year or a little more. 

Charles Bell has related the case of an infant who was run over by a diligence, 
and who died thirteen months after the accident. On examination after death, 
the last dorsal vertebra was found to be completely dislocated backward and to 
the left, upon the first lumbar vertebra. 2 

With these facts before us, I think we cannot hesitate, when the 
nature of the accident is fully made out, and especially when the dislo- 
cation has occurred in the lower dorsal vertebrae, to attempt the reduction 
by forcible extension, united with judicious lateral motion, or with a 
certain amount of direct pressure upon the projecting spines. 

§ 3. Dislocations of the Six Lower Cervical Vertebrae. 

It is much more common to meet with simple dislocations of the verte- 
brae of the neck uncomplicated with fractures, than of either of the other 
vertebral divisions. This is doubtless owing to the greater extent of 
motion which their articulating surfaces enjoy. They may be dislocated 
forward or backward. The forward dislocation may be complete or in- 
complete ; with both sides equally advanced ("bilateral" of Malgaigne), 
or one of the articulating apophyses may be dislocated forward, holding 
the opposite apophysis in its place ("unilateral" of Malgaigne). 

Schrauth 3 has collected twenty-four examples of dislocation of the cervical 
vertebra}, of which four are recorded as dislocations forward, two back, and six 
to the one side or the other. Three of this number were dislocations of the 
atlas, two were dislocations of the second vertebra, five of the fourth, two ot 
the fifth, two of the sixth, and one of the seventh. In the other cases the seat 
was not stated. Malgaigne has brought together forty-five examples ; of which 
twenty-one were complete forward dislocations, nine incomplete forward disloca- 
tions, nine unilateral and forward, and four were backward dislocations. Three 
were dislocations of the second vertebra upon the third, four were dislocations 
of the third vertebra, ten of the fourth, eleven of the fifth, fifteen of the sixth, 
and two of the seventh. 4 

Causes. — The bilateral forward dislocations are generally caused by a 
fall upon the top and back of the head, or upon the top of the head 
while the neck is very much flexed forward. The unilateral is caused 
sometimes by a direct blow upon the back of the neck, the blow being 
probably directed somewhat to one side or the other. It may also 4 be 

1 Swan, Boston Med. and Surg. Journ., vol. xxii. p. 102, March, 1840. 

2 Charles Bell, on Injuries of the Spine, 1824. 

3 Schrauth, Amer. Journ. Med. Sci., May, 1848. from Archiv fur Phys. Heilkunde. 
* For additional cases see Dublin Journ. Med. Sci., March, 1879, p. 260. 



DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRJ. 533 

caused by muscular action, and especially by the action of the sterno- 
cleido-mastoid, as in a sudden movement of the head to one side. 

Malgaigne found this to have been the cause in six of the seven cases collected 
by him. Such also was the fact in the cases reported by Rotter, 1 Foelker, 2 Koch, 3 
Schuh, Moxon, Berthold, and Wyeth, to the four latter of which I shall again 
make reference. 

The number of backward dislocations which have been reported are 
too few to enable us to indicate very accurately the general causes, but it 
seems probable that they are most often occasioned by a fall upon the 
fore and top part of the head, received while the neck is bent forcibly 
back. 

Symptoms. — In dislocations of the cervical vertebrae forward the head 
is usually depressed toward the sternum, in dislocations backward the 
head is thrown back, and in unilateral dislocations the head is turned 
over one of the shoulders. Neither of these malpositions of the head is 
uniformly present in these several dislocations, and indeed not unfre- 
quently, especially in case the system is greatly shocked by the accident, 
the head and neck assume a preternatural mobility, and may be turned 
easily in any direction. The spinous process, unless the patient is very 
fleshy or' considerable swelling has supervened, can easily be felt, and its 
•deviations to the right or to the left, forward or backward, furnish us 
with the most valuable and important sign of the dislocation. Even 
the transverse processes may be felt sometimes, especially in the upper 
part of the neck, with sufficient distinctiveness to render them useful in 
the diagnosis. To these circumstances we may add paralysis of the 
body below the seat of injury, with pain and swelling at the point of 
dislocation. In some cases also the patient has himself distinctly felt 
a cracking or sudden giving way in the neck at the moment of the acci- 
dent. 

Prognosis. — The complete bilateral dislocations, whether backward or 
forward, have in most cases terminated fatally within a short time, gen- 
erally within forty-eight hours. Unilateral dislocations are less speedy 
in their results, but when the dislocation remains unreduced, death gen- 
erally takes place in a month or two. 

Lente relates a case of incomplete dislocation of the fifth "cervical vertebra 
backward, unaccompanied with fracture, which accident the patient survived 
five days.* A patient of Roux's lived eight days; but in the case of a second 
patient mentioned by Lente, with a complete dislocation, without fracture, of 
the fifth vertebra, the patient survived the injury only two hours. 5 

On the other hand, occasional examples are presented of partial or 
complete recovery with the dislocation unreduced. 

Horner, of Philadelphia, presented to the class of medical students of the 
University of Pennsylvania, in 1842, a lad, set. 10, who had fallen a distance of 
twenty feet, alighting upon his head. He was found senseless and motionless, 
with his head bent under his body. He gradually recovered from the shock, 
but his neck was stiff, distorted and motionless, his face being inclined down- 

1 Poinsot, op. cit., p. 758. 2 Ibid. 3 Ibid. 

4 Lente, New York Journ. Med., May, 1850, p. 284. 5 Lente, ibid., p. 397. 



534 DISLOCATIONS OF THE SPINE. 

ward to the right side. Two days after, his " common and accurate perceptions 
returned, but he was affected for some time with tingling and numbness in his 
left arm." When presented to the class the transverse processes, from the fifth 
upward, were about half an inch in front of those below, showing that the left 
oblique process of the fourth was dislocated forward upon the fifth. The rotary- 
motions of the neck could not be executed to some extent, but much more freely 
to the right than to the left. Professor Horner refused to make any attempt to 
reduce the dislocation. 1 

Dr. Purple, of New York, has reported a case of what was called a dislocation 
of the fifth and sixth cervical vertebrae, producing complete paralysis of the 
lower part of the body, in which the patient survived the accident many years ; 
but his lower extremities were so useless and cumbersome as to induce him, in 
the year 1851, six years after the injury had been received, to submit to the 
amputation of both at the hip-joint. In 1852, having become very intemperate, 
he died, but no autopsy was obtained, so that the exact character of the injury 
was never ascertained. 2 Sanson, of Paris, has reported also a case which came 
under his observation at Hotel Dieu, of dislocation of the " third cervical ver- 
tebra backward," from which, although unreduced, the patient partially re- 
covered. The character of this accident was not much better determined ; for, 
although he felt a severe and sharp pain at the moment of the injury, which 
was greatly aggravated by motion, and his head was bent forward and to the left, 
'* the chin being fixed on the upper part of the sternum," there was no paralysis 
of either the motor or sentient nerves. After the lapse of about four months he 
left the hospital, still unable to lift his chin more than four inches from the 
sternum ; after which he resumed his usual occupations, suffering no further 
inconvenience than what was occasioned by the unnatural position of his head. 3 
Notwithstanding the authoritative testimony of Sanson that this was a dislocation" 
backward, one cannot avoid the conclusion that it was either an incomplete uni- 
lateral dislocation, or perhaps a mere diastasis of the articulation, or else that it 
was an example of sprain of the muscles, and consequent contraction of one set, 
or paralysis of the opposing set of muscles. It is certain that it was not a com- 
plete dislocation ; nor, since there was no paralysis of the body below the point 
of injury, can it be properly made use of as an argument for non-interference 
where such paralysis does actually exist. 

Poinsot saw, in 1883, a case occurring in a man aged 35 years, caused by the 
fall of a heavy weight upon his head while it was in a position of extension. 
He lost consciousness at once, but when he recovered his senses after a few 
moments there was no paralysis. On the following day when examined by 
Poinsot, the symptoms seemed to point to a dislocation of the fifth cervical ver- 
tebra upon the sixth, but no attempt at reduction seems to have been made. 
Gradually the head regained its position and motions, but after a time, and at 
the date of the last observation, more or less of the deformity and immobility 
continued to exist. 4 

Treatment. — The following cases illustrate what encouragement at- 
tempts at reduction may offer in cases which present so little ground of 
hope where the reduction is not accomplished. 

Dr. Spencer, of Ticonderoga, N. Y., relates that a man, set. 50, fell backward 
from a board fence, striking upon the superior and anterior portion of his head, 
dislocating the second from the third vertebra of the neck. His head was 
thrown back so far as to prevent his seeing his own body, and all below the 
injury was completely paralyzed. Repeated attempts were made to reduce the 
dislocation, "but the transverse processes had become so interlocked that every 
effort proved abortive," and he died forty-eight hours after the injury was re- 
ceived. 5 Gaitskill also attempted reduction in a case of dislocation of the 

1 Horner, Amer. Journ. Med. Sci., April. 1843, from Med. Exam. 

2 Purple, New York Journ. Med., May, 1853, p. 319. 

3 Sanson, Amer. Journ. Med. Sci., Feb. 1836, p. 514, from Gaz. des H6pitaux. 

4 Poinsot, op. cit., p. 761. 

5 Spencer, Boston Med. and Surg. Journ., vol. xv. No. 11. 



DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRA. 535 

seventh cervical vertebra, but failed. 1 Boyer failed in two cases. It is related 
by Petit Radel, that a young patient at La Charite expired in the hands of the 
surgeons, upon such an attempt being made a few days after the accident; 2 and 
Dupuytren says " the reduction of these dislocations is very dangerous, and we 
have often known an individual perish from the compression or elongation of 
the spinal marrow which always attends these attempts." 

Dr. Schuh, of Vienna, relates that a man, set. 24, while engaged at his work 
twisted his head suddenly round, in consequence of one of his companions 
roaring into his ear, when he instantly felt something give way in his neck, and 
found it impossible to move his head. Next morning his head was turned to 
the right and bent down tow T ard the shoulder. Every attempt to move his head 
caused great pain. He complained of weakness in his right arm, but all the 
other functions of his body were perfect. An attempt was immediately made 
to reduce the dislocation by lifting him by the head, but without success. On 
the second day the weakness and numbness of the right arm had increased, and 
the attempt to reduce the bones was renewed. The patient was laid horizontally 
upon a bed, and extension made from the chin and occiput while counter-exten- 
sion was made from the shoulders. The force thus employed was gradually 
increased until the patient and assistant felt a snap as of two bones meeting, 
when it was found that the head was restored to its natural position, and the 
power of moving it had returned. The next day his arm w T as more powerless 
than before, and on the following day he had vertigo, but these symptoms soon 
yielded to copious bleedings, and he left the hospital cured on the 13th. 3 

Dr. Hickerman, of Ohio, has also reported a case of dislocation of one of the 
cervical vertebrae. By exploring the pharynx a prominence was felt opposite 
the junctidn of the fourth and fifth cervical vertebras ; and the action of the 
heart was barely perceptible. Seizing the patient's head under his left arm, Dr. , 
Hickerman in this manner made traction, while with the index finger of the 
right hand in the patient's throat, he made firm pressure obliquely upward, 
backward, and to the left ; after continuing the pressure for about forty or fifty 
seconds, the part against which the finger was placed gradually yet quickly 
receded in the direction in w T hich the pressure was made, and instantly, as 
quickly indeed as the act could be possibly executed, the patient opened her 
eyes, and natural respiration was established. She then almost immediately 
became conscious of what was transpiring about her, and signified by signs, for 
she was yet unable to speak, that she had suffered pain in the epigastrium. 
Complete recovery took place. 4 

Schrauth received under his care a patient who had a dislocation of the " right 
transverse apophysis " of the fourth cervical vertebra, without lesion of the spinal 
marrow, which he reduced on the seventh day. The first attempt was unsuc- 
cessful; but the second, made with great caution, by the aid of four assistants, 
three of whom pulled the head upward, while the fourth pressed with his whole 
w r eight upon the shoulders, was completely successful. During the time that 
the traction was being made, the head w r as occasionally rotated slightly and 
moved laterally, and at the same moment the surgeon pushed firmly against the 
displaced apophysis. The reduction was attended with " various distinct crack- 
ings in the neck," which were loud enough to be heard. After some days of 
repose he resumed his occupation, no stiffness remaining in the movements of 
the neck. 5 According to Malgaigne, Newman and Seifert have each reported 
one successful case, while Barny and Malgaigne have each met with two anal- 
ogous examples successfully reduced. 

Dr. Maxson, of Geneva, N. Y., was called to see a child about 9 years old, 
who had met with a similar accident about forty hours before, namely, a dislo- 
cation of the right articulating apophysis of the fifth or sixth cervical vertebra, 
occasioned by suddenly turning her head around while at play. She at first 
complained only of pain and inability to straighten the neck; but whenever 

1 Gaitskill, London Repository, vol. xt. p. 282. 

2 Petit Radel, Note to Boyer, Malad. Chir., vol. v. p. 115. 

3 Schuh. Amer. Journ. Med. Sci., July, 1841, p. 207. 

* Hickerman, Buffalo Med. Journ., vol. x. p. 702, April, 1855. 
5 Schrauth, Amer. Journ. Med. Sci., May, 1848. 



536 DISLOCATIONS OF THE SPINE. 

moved she became faint and irritable. A short time before the surgeon was 
called, the mother had, in attempting to move her in bed, turned the face a little 
more to the left, when a severe convulsion immediately ensued. On examining 
the neck, Dr. Maxson discovered the displacement of the transverse process. 
Having advised the parents of the danger necessarily incident to an attempt at 
replacement, and of the probable consequences of its being permitted to remain 
as it was, they consented that the trial should be made. " I grasped the head," 
says Dr. Maxson, " with both hands, and proceeded according to Desault's 
method, only I first carried or turned the face very gently a little further toward 
the left shoulder to disengage, if possible, the process ; then lifting or extending 
the head, I turned the face very gently toward the right shoulder, when the diffi- 
culty was at once overcome, and she exclaimed : ' I can move my eyes.' Her 
countenance soon acquired a more natural appearance; the faintness passed off; 
she rested quietly through the night : had no return of the difficulty, and needed 
only an emollient anodyne to soothe the irritation and slight swelling which 
remained at the point o*f injury." l 

Dr. Berthold, of Nuremberg, reduced a dislocation of one of the oblique pro- 
cesses of the sixth vertebra in a boy, set. 19 years, by extension with his hands 
and rotation. 2 Dr. Wm. J. Morton, of New York, has reported a case of dislo- 
cation of the fifth oblique process in a boy 12 years old, reduced after the lapse 
of one week, by suspension of the head between the hands and rotation. 3 Dr. 
John A. Wyeth, of this city, relates a case of dislocation of the right articular 
process of the fourth vertebra forward, from muscular action, in the person of a 
lady who had turned her head strongly to the left side. Her head became fixed 
immovably ; there was great pain at the point of this articulation ; oppressed 
breathing and a numbness extending down the arm of the same side. Dr. Wyeth 
was immediately summoned and attempted to rotate the head into position, but 
was unable to do so. He then seized the head and rotated it slightly to the left, 
then made strong extension and rotated to the right, when the head returned to 
and retained its natural position. During the next two days there was consider- 
able pain along the spinal cord and in the right arm. Three months after the 
accident she was perfectly well. 4 Kust, 5 Wood, 6 of this city, and others, have 
seen and reported similar cases attended with like success. 

So far, the cases of successful reduction to which I have referred were 
examples of dislocation of only one of the articulating apophyses, and 
they have been sufficiently numerous and successful to establish the value 
of attempts at reduction. I have now to relate a case in itself almost 
unique, namely, a successful reduction of a dislocation of the fifth cer- 
vical vertebra, in which both apophyses appear to have been thrown for- 
ward. It occurred in the practice of Dr. Daniel Ayres, of Brooklyn, 
N. Y., and will be best understood by a reproduction of his own pub- 
lished account of the case : 

" E. K., the subject of this accident, was a laboring man, 30 years of age, tall 
and muscular, but not fat, with a neck longer than the average among men of 
equal height. On the evening of the 2d of October he became intoxicated ; was 
brought home insensible, and did not recover from the combined effects of the 
shock, and his libations until the following morning, when he was supposed by 
his wife to be laboring under cold and a stiff neck. She made some domestic 
applications to the affected part, and administered a dose of cathartic medicine. 
When it was thought sufficient time had elapsed without obtaining relief, he was 

1 Maxson, Buffalo Med. Journ., Jan. 1857, p. 476. 

2 Berthold, Month. Ab. Med. Sci., June, 1875. 

3 Morton, Med. Becord. Oct. 4, 1879. 

4 Wyeth, Hosp. Gaz., K Y., Aug. 1879. 

5 Bust, Chelius, note by South. 

6 Wood, New York Journ. Med., Jan. 1857, p. 13. 



DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRAE. 537 



Fig. 344. 



seen by Dr. Potter, of this city, and afterward by Dr. Cullen, both of whom rec- 
ognized a condition which was not only very unusual, but one which they had 
never before observed. I was then requested to examine the case, which I did 
on the ninth day after the accident. With some assistance, and great personal 
effort he was able to get out of bed, moving very slowly and cautiously. Desiring 
to expectorate, he was obliged to get down on his hands and knees, which he 
accomplished with the same deliberation. When seated on a chair, the head 
was thrown back and permanently fixed ; the face turned upward with an anx- 
ious expression. The anterior portion of the neck, bulging forward, was strongly 
convex, rendering the larynx very prominent. The integuments of this region 
were exceedingly tense and intolerant of pressure. The posterior portion of the 
neck exhibited a sharp, sudden angle at the junction of the fifth and sixth cer- 
vical vertebrse, around which the integuments lay in folds. It was difficult to 
reach the bottom of this angle even with strong pressure of the fingers, and, of 
course, the regular line formed by the projecting spinous processes was abruptly 
lost. He complained of intense and constant pain at this point, which was 
neither relieved nor aggravated by pressure. With difficulty he swallowed small 
quantities of liquid, pausing after each effort, and could not be induced to take 
solid food, since the first attempt to do so after the accident was followed by vio- 
lent paroxysms of coughing and choking. His breathing was obstructed and 
somewhat labored, being unable fully to clear the bronchi of their secretion. 
This, however, seemed rather an effect of the tense condition of the soft parts of 
the neck, than the result of pressure upon the spinal cord, since he presented no 
evidence of paralysis, either of motion or sensation, in parts below the neck. 
The sterno-cleido-mastoid muscles of both sides were felt quite soft and relaxed. 

" But one conclusion could be formed upon this state of facts, to wit : that the 
oblique processes of both sides were completely dislocated. The marked rigidity 
of the head seemed to preclude the proba- 
bility of fracture through the vertebral 
bodies, and although the cartilage might 
be separated anteriorly, yet the body not 
pressing backward sufficiently to produce 
paralysis of the cord, it was hoped that the 
posterior vertebral ligament remained un- 
injured ; it was, therefore, determined to 
make an effort at reduction on the follow- 
ing day. In addition to those originally 
connected with the case, I am under obiga- 
tions to Drs. Ingraham, Turner, Palmedo, 
G. D. Ayres, and a number of other medical 
gentlemen, who were present by invitation, 
all of whom confirmed the diagnosis, and 
rendered efficient services. 

" The patient was placed upon a strong 
table, in a recumbent position, with a 
pillow resting under the shoulders, the 
head being supported by the hand during 
the administration of chloroform, of which 
an ounce was given before anaesthesia en- 
sued. Counter-extension being made by two 
folded sheets placed obliquely across the 
shoulders and properly held, the head was 
grasped by one hand placed under the chin, 
the other over the occiput, and by steadily 
and firmly drawing the head directly back- 
ward, and then upward, an attempt was 
made at reduction, but failed for want of 
sufficient power. Dr. Ingraham was then 
requested to place his hands immediately 
over my own in the same position as before, 
and steady traction was again made in the same direction. Our united strength 
was required in drawing the head backward and upward to dislodge the superior 




Ayres's case of bilateral dislocation of 
the fifth cervical vertebra. 



538 DISLOCATIONS OF THE SPINE. 

oblique processes from their abnormal position. When this was felt to be yield- 
ing by Dr. Cullen (who kept one hand constantly at the seat of dislocation), 
Dr. Potter was directed to place his hands under our own, still in position, 
and assist in bringing the head forward; at the same time the chest was de- 
pressed toward the table. The bones were distinctly felt to slip into their places ; 
the line of the spine was instantly restored, the head and neck assuming their 
natural position and aspect. As soon as the patient became conscious, he ex- 
pressed himself ignorant of what had taken place, but free from pain, and, in 
his own language, 'all right.' A bandage was arranged to support the head 
and keep it bent forward. He had an anodyne for two nights following, 
after which no further treatment was necessary, and at the end of one week 
he had complete control over the movements of the head and neck. Beyond 
the debility and emaciation immediately dependent upon protracted fasting 
and loss of rest, he has experienced no uneasiness since the operation. His 
appetite is now good, and all the functions perform their duty normally. In 
a subsequent inquiry, to determine, if possible, the cause of the accident, he 
states that he distinctly recollects going into a store in Atlantic Street, near the 
ferry, and there having angry words with an acquaintance ; that he left the store, 
and was proceeding up the street (which is here a rather steep ascent), when he 
was violently struck from behind, over the lower portion of the neck. He like- 
wise remembers falling forward, and striking against some object, but he does 
not know what it was, nor what took place until the following morning." * 

So far as I know, the only other example of supposed successful reduction of 
a complete bilateral dislocation of these vertebrae has been reported by Vrig- 
nonneau; 2 but of which Malgaigne expresses some doubt as to whether it was 
an example of partial or complete dislocation. After alluding to Gosselin's suc- 
cess upon the cadaver, Malgaigne says: 3 "Some surgeons have even thought 
that they had obtained it upon the living subject. M. Vrignonneau was called 
to see a man 39 years of age, who had just fallen upon the head from a height of 
six metres. The face was bent upon the chest ; the whole body was rigid, and 
was raised as if all of a piece; the patient, however, could still move his limbs. 
The surgeon diagnosticated — but he does not say how — a dislocation forward of 
the fifth cervical vertebra ; and at first he did not dare to interfere. The next 
day, however, all the limbs were paralyzed ; the following day death was immi- 
nent, as shown by the stertorous respiration and by the almost imperceptible 
pulse; he then concluded to try the reduction, which was accomplished with a 
distinct craquement. From that time all the symptoms subsided as if by enchant- 
ment, and two months later the man could work, there remaining only some 
stiffness in the neck, especially during the lateral movements, which remained 
quite limited. I praise the fortunate determination of the surgeon ; but I regret 
that the diagnosis was not more fully established; and even while admitting the 
forward dislocation, the absence of paralysis(?) leaves one in doubt as to whether 
it was not an incomplete dislocation, such as those we are about to consider." 

§ 4. Dislocations of the Atlas. 

Surgeons have met with several forms of displacement between the 
atlas and axis. First, a forced inclination forward of the atlas upon the 
axis ; in consequence of which the body or anterior arch of the atlas is 
made to recede from the odontoid process, and the transverse ligament 
glides upward without breaking ; so that the extremity of the odontoid 
process comes to occupy a position underneath or behind the ligament, 
and thus presses upon the cord. It is apparent, also, that this form of 
displacement cannot occur without a rupture of the vertical ligaments 
which bind the transverse ligaments to the axis ; nor without a separa- 

1 Ayres, New York Journ. Med., Jan. 1857, p. 9. 

2 Vriguonneau, Journ. des Conn., Med. Chir., t. 1, p. 21. 

3 Malgaigne, op. cit , t. 2, p. 363. 



DISLOCATIONS OF THE ATLAS. 539 

tion of the atlas fiom the axis posteriorly and a rupture of the posterior 
atlo-axoidean ligament. Second, a similar inclination of the atlas, ac- 
companied with a rupture of the transverse and superior vertical liga- 
ments, in consequence of which also the odontoid process is allowed to fall 
upon the cord. Third, the atlas in the same position, with the odontoid 
process broken at its base. Fourth, the atlas displaced directly forward 
or backward. Fifth, a displacement of only one articular process in a direc- 
tion forward ; and sixth, a displacement of one articular process forward, 
and of the other backward. 

I have already, when speaking of fractures of the atlas, or of the 
atlas and axis together, called attention to several examples of that form 
of the dislocation which is accompanied with a fracture of the odontoid 
process. The other forms of dislocation are characterized by so few 
symptoms peculiar to themselves, or which can be regarded as diagnostic 
and not already sufficiently studied in connection with other dislocations 
of the neck, that I shall not deem it necessary to do more than remind 
my readers, that if permitted to remain unreduced a speedy and fatal 
issue is inevitable, and to point them to some examples of recovery, after 
reduction has been fortunately accomplished. These may suffice to show 
that Dupuytren was in error when he declared that such accidents were 
wholly beyond the resources of our art. 

An old man received upon his head a bundle of hay cast from the top of a 
wagon. He fell with his head bent forward so that his chin touched the top of 
the sternum, and in this position it remained immovably fixed; all the other 
portions of his body preserving their natural functions. A surgeon, who was 
indeed the father of Malgaigne, being called, assured the patient, that unless he 
could give him relief he certainly would die ; but that inasmuch as the attempt 
might itself prove fatal, he ought at once to put in order his affairs. Accord- 
ingly the man partook of the sacrament; then the surgeon seated him upon the 
ground, and placing himself at his back with his knee resting upon his shoulders 
for the purpose of making counter-extension, and with a towel brought over his 
own shoulders and under the chin of the patient for extension, he proceeded to 
act upon the neck in the direction of the axis of the spine. The efforts were 
long and painful ; but at last, while the head was lifted, as far as possible, it was 
suddenly drawn backward, and immediately it resumed it natural direction. 
Absolute quietude was enjoined, and the patient recovered in a short time and 
without any -accident. 

Another example is related by Ehrlich, but in this case the dislocation was 
backward. A young man, aet. 16, while carrying a sack of flour up a ladder, fell 
backward, and the sack falling over upon his face and head came to the ground 
before him. He was found lying with his head thrown back and to the right, 
the head resting upon the scapula of this side, but having so completely lost its 
" solidity" that by its own weight it would fall from one side to the other. On 
the front and left side of the neck there existed a prominence supposed to be 
formed by the atlas ; the patient was unconscious ; the pulse was scarcely per- 
ceptible, and the whole body was suffering under paralysis. Ehrlich directed 
the shoulders to be held by one assistant, and the head to be drawn upon by 
another, while he pressed with his own hands forcibly upon the displaced atlas 
from behind. After several fruitless attempts, the reduction took place, accom- 
panied with a sound distinctly audible to all of the assistants ; the head resumed 
its position firmly, and the arms began to move. The head was afterward main- 
tained in place by a bandage. The cure proceeded rapidly, and after a time no 
trace of the injury remained but a disagreeable tension in the nape of the neck 
whenever he moved his head briskly to the one side or the other. 1 

1 Malgaigne, Ehrlich. Malgaigne, op. cit., torn. ii. p. 334. 



540 DISLOCATIONS OF THE SPINE. 

Peabody, 1 in the case of a man who had subluxation of the atlas, occasioned 
by a fall from a height upon his head, and in whom death seemed imminent, 
succeeded after several trials. The patient was unconscious, his eyes were 
closed, and his pupils dilated. Immediately upon the reduction having been 
effected, which was accompanied with a violent craquement, the patient opened 
his eyes, spoke to those who were about him, and complained of pain in the 
back of his neck. On the following day he could be considered as in his normal 
condition. 

Uhde, Wagemann, and Boettger, of Braunschweig, report a case of bilateral 
dislocation of the atlas, in which the right inferior articular process of the atlas 
was displaced forward, in front of the corresponding superior articular surface of 
the axis, and the left inferior articular surface of the atlas backward, behind the 
corresponding superior articular surface of the axis, as shown by the position 
of the left transverse process of the atlas. " The patient, a roofer, fell from a 
height of thirty feet. The head was rotated upon all three of its axes, the right 
half of the face being turned forward, the facial line forming an angle with the 
median line of the body, and the chin thrown forward, and the forehead back- 
ward. On the left side there was paralysis of the plexus pharyngeus and the 
hypoglossal nerve; on the right, simply paralysis of the glosso-pharyngeus. 
Careful anatomical and experimental research proved that the injuries of the 
nerves depended upon the dislocation. The nervus accessorius W. also suf- 
fered at a point corresponding to that on the hypoglossus, and to this the paral- 
ysis of the left velum palati, observed in the patient, was attributed; the plexus 
pharyngeus, of which the anterior branch of the accessorius forms a part, suffer- 
ing by traction on the trunk of the nerve. The experiments also proved that, 
in this dislocation the cord is not subjected to pressure, and that the vertebral 
artery is not injured. The dislocation was partially reduced two days after the 
accident by extension, extreme flexion of the head on the left shoulder, and 
rapid rotation backward and to the right, together with direct pressure upon the 
left transverse process of the atlas. The condition of the patient improved 
materially after extension had been made for some time with Glisson's appa- 
ratus. After the lapse of several weeks the patient was able to move his head 
in every direction. Barely a trace of the paralysis remained.'' 2 

Bernhuber 3 treated a young man who had fallen, striking the back of his neck 
upon a piece of furniture. He lost consciousness, but when a point opposite the 
atlas was pressed upon he became convulsed. On the second day the convul- 
sions were continuous, and death seemed imminent. The surgeon seized the 
head with both of his hands, and made traction upward, when the patient opened 
his eyes and became conscious. By means of bandages and a gallows the head 
was maintained in that position. All symptoms at once disappeared, but it was 
observed that whenever the extension ceased and the head was permitted to fall 
upon the trunk, the somnolency was prone to return, and for this reason the 
extension was continued. The patient recovered, with only a slight rigidity of 
the neck. 

§ 5. Dislocations of the Head upon the Atlas, or Occipito-atloidean 

Dislocations. 

It is unnecessary to say that only in examples of partial dislocation of 
the head could a hope be entertained that surgical resources would be of 
any avail ; and even in these cases death has, in all the reported exam- 
ples, taken place- too speedily to permit surgical interference. 

Lassus, Palletta, and Bouisson 4 have each reported one example of this dislo- 
cation. In neither case was the dislocation complete, but death occurred speedily 

1 Peabody, Boston Med. and Surg. Journ., 1876, vol. ii. p. 79. 

2 St. Louis Courier of Med., Jan. 1879, from Arch, fur klin. Chirurg, Sept. 1878. 

3 Bernhuber, Denuce, Art. Region Atloidienne, Nouv. Die. de Med.et de Chir. Prat. t. 3, 
p. 809. (Poinsot, op. cit., p. 722.) 

4 Lassus, Palletta, Bouisson. Malgaigne, op. cit., p. 320. 






DISLOCATIONS OF THE RIBS FROM THE VERTEBRAE. 541 

in every instance. Dariste exhibited to the Anatomical Society of Paris, in 
1838, a specimen of incomplete dislocation of the occipito-atloidean articulation, 
with stretching of the transverse ligament; the patient from whom the specimen 
was taken having lived more than a year after the accident, when he died from 
a tubercle in the brain. 1 

Milner, of London, 2 has reported a case of complete dislocation of the head 
upon the atlas. A man, set. 38, fell from a height of seventy feet, and was killed 
instantly. On examination it was found that all the ligaments uniting the 
occiput with the atlas were ruptured, and dislocation was complete. The pos- 
terior arch of the atlas was fractured ; the spinal marrow, the two arteries, and 
the two vertebral veins were ruptured. 



CHAPTEE V. 



DISLOCATIONS OF THE RIBS. 

The ribs may be separated from the bodies of the vertebrae, from the 
cartilages of the ribs, and from each other. The cartilages of the ribs 
may also be separated from the sternum. 

§ 1. Dislocations of the Ribs from the Vertebrae (Vertebro-costal). 

The heads of the ribs are joined to the bodies of the vertebrae by 
strong ligaments. The articulations are ginglymoid, admiting of motion 
chiefly in the direction of the axis of the spine. The mobility gradually 
increases as we proceed from the first rib downward to the last. Each 
joint is furnished with a capsule. The necks and tubercles are also 
united to the transverse processes by ligaments, and the articulations are 
furnished with synovial capsules. I am not aware that any examples 
have ever been reported of dislocations of the ribs from the transverse 
processes. 

Examples of dislocation of the heads of the ribs have been mentioned by 
Ambrose Pare, Bransby Cooper, Alcock, Donnie, Henkel, Kennedy, Buttet, and 
some others; but most of these reputed cases have not borne the test of a critical 
analysis, and while Vidal (de Cassis) is in doubt whether the claims of even one 
have been fully established, Boyer denies absolutely its possibility. We see no 
reason, however, to question the authenticity of several of these examples. The 
case mentioned by Bransby Cooper, although very briefly narrated, leaves no 
room for doubt as to its real character. " Mr. Webster, surgeon to St. Albans, 
when examining the body of a patient who had died of fever, found the head of 
the seventh rib thrown upon the front of the corresponding vertebra, and there 
ankylosed. Upon inquiry, Mr. Webster learned that this gentleman, several 
years before, had been thrown from his horse across a gate, for which accident 
he had been subjected to the treatment usually followed in fractures of the ribs, 
and there is every reason to believe that it was at this time the dislocation 
occurred." 3 

1 Dariste, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives Gen., May, 1838. 

* 2 Milner, St. Barthol. Hosp. Eep., vol. x. 

3 Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450. 



542 DISLOCATIONS OF THE RIBS. 

Causes. — These accidents seem to have been generally occasioned by 
a fall or a blow upon the back, and the dislocation has been accompanied, 
usually, with a fracture of some other rib, or of the transverse or spinous 
processes of the corresponding vertebrae. The head of the rib has always 
been found to be displaced inward. The lower ribs, including the false 
and floating, are those which have been most frequently displaced. 

Symptoms. — It would be difficult, if not impossible, during the life of 
the patient, to make a positive diagnosis, since the symptoms resemble 
so closely those which accompany a fracture of the rib near its posterior 
extremity. The nature of the accident producing the dislocation, the 
depression, mobility, and pain, are equally indicative of a fracture ; while 
the failure to detect crepitus might easily be explained by the thickness 
of the muscular wall at this point, or by the riding, or by other displace- 
ments of the broken fragments. Chelius speaks of a peculiar "rustling," 
perceived when the body and ribs are moved by the surgeon or by the 
patient himself, and which is different from the sensation produced by 
emphysema or fracture. 

The treatment ought to be the same which would be adopted in case 
the rib was broken. Replacement of the dislocated bone must be re- 
garded as impossible ; and it only remains that we insure quiet as far 
as possible in this portion of the chest, and combat the pain and inflam- 
mation by suitable remedies. 

The circular bandage, however, recommended in these cases by Sir Astley 
Cooper, could only be serviceable in dislocations of those ribs which have an 
attachment to the sternum. The floating ribs, which have been found dis- 
located quite as often as either of the others, could derive no support from cir- 
cular pressure, or from any other mechanical contrivance. 



§ 2. Dislocations of the Cartilages of the Ribs from the Sternum 
(Chondro-sternal). 

The cartilage of the first rib has no proper articulation at either ex- 
tremity, but the remaining six upper ribs, where they join the sternum, 
are furnished with synovial capsules. In old age these articulations 
generally disappear, but not always. 

Charles Bell observes: "A young man playing the dumb-bells, and throwing 
his arms behind him, feels something give way on the chest; and one of the 
cartilages of the ribs has started and stands prominent. To reduce it, we make 
the patient draw a full inspiration, and with the fingers knead the projecting 
cartilage into its place. We apply a compress and bandage, but the dislocation 
is with difficulty retained." Ravaton, Manzotti, and Monteggia have each, 
according to Malgaigne, reported one example of traumatic dislocation ; in all 
of which the cartilages were thrown forward in advance of the sternum. When 
treating of fracture of the sternum, I have related one case, which came under 
my own observation, of dislocation of three or four cartilages at the same time. 

Dr. Flagg, of St. Paul, Minn., relates the following case: A girl, set. 10, while 
playing with several children, ran violently against the corner of an ordinary 
deal-table. It is stated that the child was faint and breathed with difficulty for 
a short time, but soon returned to play. No swelling or other evidence of injury 
was observed by her friends. About forty-eight hours after receiving the injury, 
while exercising somewhat violently, she complained of sudden pain at the left 



DISLOCATIONS OF ONE CARTILAGE UPON ANOTHER. 543 

costo-sternal articulation and a sensation of something having given way. Soon 
afterward I saw the child for the first time, and found a slight non-crepitant 
swelling at the latter point, and the sternal extremity of the cartilage of the 
fourth rib displaced forward, its posterior surface being very nearly on a plane 
with the anterior surface of the sternum. A minute fragment of bone uncon- 
nected with the sternum or cartilage w r as noticed, which I took to be a fragment 
chipped off from the margin of the articular depression on the edge of the 
sternum. Neither pain nor embarrassed respiration was notably prominent ; 
crepitus could be detected, but not very distinctly ; preternatural mobility was 
very evident." 1 

By pressure alone restoration has generally been effected, the cartilage 
resuming its position suddenly and with a sound. The reduction may, 
nevertheless, be facilitated by bending the trunk backward, or by direct- 
ing the patient to make a full inspiration. To maintain the reduction 
has been found more difficult, and Sir Astley directs that " a long piece 
of wetted pasteboard should be placed in the course of three of the ribs 
and their cartilages, the injured rib being in the centre ; this dries upon 
the chest, takes the exact form of the parts, prevents motion, and affords 
the same support as a splint upon a fractured limb. A flannel roller is 
to be applied over this splint, and a system of depletion pursued, to pre- 
vent inflammotion of the thoracic viscera." Instead of the pasteboard, 
we might use either felt, sole-leather, or gutta-percha. 

Mr. Bransby Cooper says that a' baker's boy applied for relief at Guy's Hos- 
pital, who was the subject of displacement of the cartilages of the fifth and sixth 
ribs from their junction with the sternum, produced partly by the constant 
action of the pectoral muscles in kneading bread, but principally by his defec- 
tive constitution. 2 

The outer extremities of these cartilages being continuous with the 
bony structure of the rib, and destitute, therefore, of articular or synovial 
surfaces, may be subject to fracture, but not, properly speaking, to dis- 
location. 

§ 3. Dislocations of One Cartilage upon Another. 

The cartilages on the sixth, seventh, and eighth ribs are furnished at 
their lower borders with a true arthrodial joint, by which they articulate 
with the corresponding cartilages. This arrangement sometimes extends 
to the fifth and ninth ribs. A displacement of these articulations may 
take place when one falls upon his back, striking upon some projecting 
body, so that the chest is suddenly thrown forward ; in consequence of 
which the upper margin of the lower cartilage is depressed and entangled 
behind the lower margin of the upper. The inferior cartilage is, there- 
fore, the one which is displaced rather than the superior, although this 
latter, being made prominent by the pressure of the other from behind, 
seems alone to be displaced. Boyer, Martin, and Malgaigne 3 have each 
reported one example. It is probable that the contraction of the pec- 
toral and abdominal muscles has a chief agency in the production of these 

1 Flagg, Northwestern Med. and Surg. Journ., Aug. 1871. 

2 B. Cooper's ed. of Sir Astley Cooper, etc., op. cit., p. 447. 

3 Malgaigne, op. cit., p. 398. 



544 DISLOCATIONS OF THE CLAVICLE. 

dislocations, and that they are not solely or directly due to the shock of 
the accident. . 

The treatment consists in pressing firmly upward and backward 
against the inferior margin of the upper, or overlapping rib, so as to dis- 
engage it from the lower, when by its own elasticity it will resume its 
natural position. The reduction might also be aided by a full inspiration. 



CHAPTER VI. 

DISLOCATIONS OF THE CLAVICLE. 

Of 57 dislocations of the clavicle observed and recorded by me, 13 belonged 
to the sternal end and 44 to the acromial. Of those belonging to the sternal 
end, 11 were dislocations forward, forward and upward, or forward and down- 
ward, and 2 were upward. I have never met with a dislocation backward. Of 
the acromial dislocations the whole number were dislocations upward, or upward 
and outward. 

§ 1. Sterno-clavicular. 

Dislocations of the Sternal End of the Clavicle Forward.—This 

accident is generally caused by a fall upon the point — outer surface — of 
the shoulder, in consequence of which the sternal end of the clavicle is 
driven forcibly inward and forward. It is probable, also, that the blow 
which produces the dislocation is received rather upon the anterior and 
outer than exactly upon the outer face of the shoulder. A sudden effort 
of the muscles, as in the attempt to balance a weight upon the head, or 
to throw the shoulders backward when under drill, has been known also 
to produce this dislocation. In one example, it was occasioned by placing 
the knee against the spine and drawing the shoulders forcibly back. 
Various other accidents, the philosophy of whose agency is not so easily 
explained, are said to have produced the same result ; but it is not im- 
probable that in many of these cases the precise manner in which the 
injury was received has not been correctly understood or reported. 

Mr. Fergusson has once seen this displacement in a newly-born infant, which 
had happened during birth. It could be replaced with ease, but immediately 
slipped out again when left to itself. "Nothing was done ; a new joint formed, 
and the child afterward possessed as much power in the one arm as in the 
other ; m and Dr. Shaw, of Pittsburg, Pa., has also seen a congenital case. 2 The 
following is an example of double forward dislocation at the sternal end : A. M., 
set. 17, in a collision on the railroad, was thrown violently, it is supposed, against 
the door, striking her left shoulder, and then by a rebound striking the floor of 
the car with the right shoulder. I saw her on the fourth day after the accident. 
Exposing her shoulders, we observed an extensive ecchymosis on the outer 
surface of the right shoulder, extending some distance down the arm. While 
seated in a chair both clavicles were subluxated forward and a little upward, 
the right ascending a little higher than the left. She could not raise her arms 

1 Fergusson, System of Practical Surgery, Amer. ed., 1853, p. 203. 

2 Shaw, Med. Eecord, Aug. 18, 1877. 



STERNO-CLAVICULAR. 



545 



to her head ; but when lifted to this position the dislocations became complete, 
and when let fall bones would resume their positions of subluxation with a click. 
The bones could not be pushed completely into their sockets, and pulling the 
shoulders back increased the displacement ; but when lying flat on her back 
they went nearly into place. At my suggestion, she was kept in this position 
six weeks, but with no result ; the bones still becoming displaced whenever she 
got up. Some months after the accident she was still suffering from the general 
disturbance to her spine and nervous system caused by the shock, and the arms 
had not recovered their original strength. It seems probable, from the history 
of the case as subsequently ascertained, that there had existed prior to the acci- 
dent a laxity of the capsule, permitting of the existence of a partial displace- 
ment, and which was rendered complete by the traumatism. 

[Duckett, 1 of Manchester, reports a case of ante-sternal dislocation which 
occurred while swimming.] 

Symptoms. — The head of the bone, unless the person is exceedingly 
fat, or great swelling has supervened, can be distinctly felt and seen in 
front of the sternum ; the corresponding shoulder falls a little back ; the 
head inclines also sometimes to the same side ; the movements of the arm 
are embarrassed, and accompanied almost always with an acute pain 
at the point of dislocation. The clavicular portion of the sterno-cleido- 
mastoid muscle presents an unusually sharp and projecting outline, and 
a careful measurement indicates, if the dislocation is complete, a sensible 
approach of the acromion process toward the centre of the sternum. If 
now the surgeon places his knee against the spine, and draws the shoul- 
ders back, the projection of the clavicle in front usually diminishes or 
disappears ; if he carries the shoulder up, it descends ; and if he depresses 



Fig. 345. 



Fig. 346. 





Dislocation of the sternal end forward. 



Appearance of a dislocated clavicle. 



the shoulder, it ascends. The simplicity and uniformity of the symptoms 
which usually characterize this accident will generally prevent the possi- 
bility of a mistake. 

Pinel mentions the case of a man who, having presented himself at one of the 
hospitals of Paris, suffering under this dislocation, the surgeon-in-chief thought 
it a tumor of the bone, and advised the application of a plaster; and, on the 
other hand, a patient presented himself to Velpeau, who had been treated for a 
dislocation, when the bone was only expanded by disease. I have myself also 
seen a fracture so near the sternal end of the bone as not to be easily distin- 
guished from a dislocation. 

1 London Lancet, Oct. 6, 1888. 
35 



546 DISLOCATIONS OF THE CLAVICLE. 

Pathology. — In complete anterior dislocation of the clavicle, the cap- 
sular ligament suffers a complete disruption, and also the anterior with the 
posterior sterno- clavicular ligaments. The rhomboid and interarticular 
ligaments suffer more or less, according to the extent of the displacement. 
The interarticular cartilage may retain its attachment to the sternum, or 
it may be carried forward with the clavicle. The head of the bone lies 
immediately underneath the skin and in front of the sternum ; and gen- 
erally it is found to have descended a little upon its anterior surface. 

Richerand saw a case in which the sternal extremity of the bone was placed 
three inches below the top of the sternum. In some cases it is situated in front 
and a little above the sternum. Wherever the bone lies, it carries with it the 
clavicular fasciculus of the sterno-cleido-mastoid muscle. 

Treatment. — Not one of the 11 forward dislocations of the clavicle at 
the sternal end seen by me has been completely reduced, or if reduced 
they have not been retained in place. In the following example the 
reduction, although faithfully attempted, was never accomplished. 

Mr. H., of Buffalo, set. 45, was thrown by a horse, suffering at the same 
moment a fracture of the leg and a forward dislocation of the left clavicle at its 
sternal end. Prof. J. P. White, with whom I was in consultation, made several 
attempts to reduce the dislocation by placing the knee against the spine and 
pulling the shoulder forcibly back, and the same efforts were repeated by myself, 
but without accomplishing the reduction. We also endeavored to reduce it by 
pressing directly upon the projecting bone and by placing a pad in the axilla, 
using the arm as a lever, as recommended by Desault, and with no better result. 
The patient was tolerably muscular, but while we were manipulating he was 
very much enfeebled by the shock of the accident. Finding that it was impos- 
sible to reduce the dislocation by any moderate amount of force, and believing 
that if it were to succeed we could not retain the bone in place, and the more 
especially because his left side was so much bruised that he could not bear an 
axillary pad or bandages of any kind, we desisted from any further attempts. 
Two years later I examined the shoulder and found the clavicle still unreduced, 
and its position unchanged. When he carries the shoulder forward or backward 
there is a corresponding motion at the sternal end of the clavicle. The arm is 
not quite as strong as the other, and its freedom of motion is slightly impaired. 
I have also in my museum the cast of a case of complete forward dislocation 
at this point; which accident occurred in a lad twelve years old, who had fallen 
into a cellar. The late Dr. Lewis and Dr. Dayton, both excellent surgeons, had 
examined the arm, and dressings had been applied with a view to maintain the 
reduction ; but on the fifth day after the accident I found the bone displaced ; 
nor do I think reduction was ever afterward maintained. 

A lad was brought into the Buffalo Hospital with a dislocation of the same 
character, who had been run over by a wagon on the same day. Dr. E. P. 
Smith, one of the surgeons of the hospital, attempted faithfully to reduce it, but 
was unable to do so. Five days after, I found the bone out and quite movable. 
All apparatus having been removed, we laid him upon his back in bed, and kept 
him in this position three weeks. He was then dismissed with no change in the 
appearance of the bone, but he could move the arm as well as before the acci- 
dent. Surgeons have not met with, or, at least, they have not mentioned, any 
cases in which the reduction of this dislocation was attended with difficulty, 
nor am T prepared to explain the difficulty which was experienced in my own 
(Mr. H.) and in Dr. E. P. Smith's case; unless it be as suggested by Sedillot, 
and as illustrated by Smith's case of dislocation upward hereafter to be men- 
tioned, that the reduction was prevented by the displacement of the inter-artic- 
ular cartilage. But most surgeons have testified to the difficulty of retaining it 
in place when reduction has been fairly accomplished. 

Nevertheless, Desault (or, rather, his pupil Bichat, who has published his 
lectures), who always speaks very confidently of his ability to retain either 



STERNO-CLAVICULAK. 



547 



broken or dislocated bones in their places, says that he " almost always obtained 
complete success " with his apparatus. It is remarkable, however, that of the 
three examples furnished by Bichat to confirm this statement, all of which were 
treated by Desault himself, one recovered after a long time with with a "very 
perceptible protuberance in front of the sternum," one with a " very slight pro- 
tuberance," and in the other the " swelling was almost gone" on the twentieth 
day, and we are left in doubt as to 

whether the reduction was any more Fig. 347. 

complete than in either of the other 
cases. 1 Richerand and Guersant 
succeeded no better with Desault's 
dressings. 2 

Other surgeons have made sim- 
ilar claims for their own forms of 
apparatus, but experience still 
continues to show that a complete 
retention of the dislocated bone 
is seldom to be expected. 

Sir Astley Cooper recommends 
an apparatus, the construction and 
application of which are illustrated 
by the accompanying sketch, the 
object of which is to draw the 
shoulders back, and at the same 
time, by the aid of two pads or 
cushions in the axillae, to carry the 
shoulders outward. The dressing is 
then completed by placing the arm 
in a sling. He advises, however, 
that in some way direct pressure 
should be made upon the projecting 
point of bone. 

Velpeau objects to any plan which 
will draw the shoulders back; but, 

on the contrary, he thinks that the shoulders should be kept slightly forward, so 
as to diminish the tendency of the sternal end of the clavicle to escape in.this 
direction. 

[Dr. Holden reports a case of dislocation of the clavicles occurring while 
practising in a gymnasium. The reduction was effected, and the bones were re- 
tained in position six months, when they were displaced while putting on a coat. 
This was now often repeated until an apparatus was applied consisting of a 
leather splint shaped like the sternum with projections at the upper angles 
covering the sterno-clavicular articulations. This splint was moulded into posi- 
tion when wet, and the articulations were thus completely and firmly supported. 
The leather was then lined with buckskin and firmly retained in position by 
straps extending from each angle over the shoulders and back, led to a broad 
belt around the waist, the lower end being also fastened to the waist-belt. With 
prolonged use of this splint recovery was effected. 3 ] 

Treatment. — Until further observations have determined the relative 
value of these and of many other processes, it will be well to adopt no 
fixed rule of action ; but having reduced the bone by either placing the 
knee upon the spine and drawing the shoulders back, or by making use 
of the humerus as a lever, the surgeon should attempt to maintain it in 




Sir Astley Cooper's apparatus for dislocated 
clavicle. 



1 Desault on Fractures and Dislocations, by Xav. Bichat, Philada. ed., 1805, p. 52. 

2 Malgaigne, op. cit., torn. ii. p. 417. 

3 New York Med. Journ , 1873. 



548 



DISLOCATIONS OF THE CLAVICLE 



place by such means as the experiment shall prove are most successful. 
Among these means, direct pressure upon the sternal end of the clavicle, 
the sling, and perfect quietude of the muscles of the arm through the 
aid of bandages, with the dorsal decubitus, are no doubt of the greatest 
importance. If we find that a position of the shoulders more or less 
forward or backward best maintains the apposition, this position, what- 
ever it is, ought to be continued. 

In order to be successful, sufficient time must elapse for the torn liga- 
ments to become firmly reunited, during which the reduction must be 
constant ; since every time the bone escapes, the whole work of repair 
has to be recommenced as from the beginning. To this end. at least four 
or six weeks are necessary, and sometimes the period must be lengthened 
far beyond these limits ; so that it may often become a grave point of 
inquiry whether the long confinement of the limb will not entail more 
serious consequences than have ever been known to arise from leaving 
the bone displaced. In no case seen by me has the function of the arm 
been very seriously impaired by the displacement. 

Dislocations of the Sternal End of the Clavicle Upward. — R. W. 
Smith 1 has furnished us with an account of one example of this disloca- 
tion as seen in the dissection. The extremity of the left clavicle rested 
upon the sternum, and had passed the median line until it touched the 
sterno-cleido-mastoid muscle of the right side. Posteriorly it rested upon 
the sterno-hyoideus muscle and the front of the trachea. The anterior 
and posterior ligaments of the joint, as well as the rhomboid ligaments, 

Fig. 348. 




Dislocation of sternal end of clavicle upward. (E. W. Smith.) 

were torn. The inter-articular cartilage was detached from the sternum 
and the cartilage of the first rib, and had followed the clavicle. 

Malgaigne has collected four undoubted examples of this dislocation. Mr. 
Bryant mentions two cases seen by himself, one of which was a double disloca- 
tion. He refers also to a specimen in Guy's Museum, dislocated upward and 
forward. 2 Dr. Shaw, of Pittsburg, Pa., has reported a case in an adult caused 



1 Smith, Dublin Journ. of Med. Sci., Dec. 1872. 

2 Bryant, Practice of Surgery, p. 787, London, 1872. 



STERNO-CLAVICULAR. 549 

by a fall. 1 Vanvert has reported a case caused by a blow upon the side of the 
chest, which he was unable to reduce. 2 The following very extraordinary case 
was described by Dr. Rochester to the Buffalo Medical Association. I saw the 
case several times. 3 J. McA., set. 44, while seated upon a load of wood, was 
caught under the bar of a gateway and violently crushed, the right shoulder 
being forced downward and a little backward. Dr. Rochester saw him very 
soon after the accident. On examination, it was found that the sternal extremity 
of the right clavicle was thrown upward so far as to rest upon the front of the 
thyroid cartilage, occasioning considerable pain, difficulty of respiration, and 
loss of speech. Reduction was easily effected, and a retentive apparatus was 
immediately applied, consisting of a gutta-percha splint, moulded to the clavicle 
and ribs, and retained in place with adhesive plaster. Suitable bandages, a 
sling, etc., were also employed to maintain complete rest. Notwithstanding all 
the care employed, the bone again became displaced, and nearly four months 
after the accident we found the sternal end of the clavicle carried upward half 
an inch, and across toward the opposite side also about half an inch, and pro- 
jecting somewhat in front. It was fixed in this position by ligaments which 
allowed it to move much more freely than natural, but which would not permit 
any great displacement. The corresponding shoulder was slightly depressed. 
He said that he felt no inconvenience or abatement of strength in the arm except 
when he attempted to lift weights above his head. 

I met with a similar case in a woman fifty years of age, which had been caused 
by a fall upon the shoulders nine weeks before, and which had been overlooked 
by her surgeon in the first instance. When seen by me it was immovably fixed 
in its new position. 

[Dr. Finley, 4 of Queensland, reports the following case : A man was riding 
home on a dark night, when his horse stumbled over a cow, throwing him with 
great force upon his right shoulder, the deltoid muscle receiving the force of the 
fall, and causing an upward dislocation of the clavicle at its sternal end. When 
I was called in, reduction of the dislocation had been obtained by the previous 
attendant, the treatment being loose bandages for the arm ; and the injury was 
reported to be the same as when first incurred. Examination showed that the 
sternal extremity of the clavicle was pushed up in the neck, so as nearly to 
touch the cricoid cartilage, and causing some pain in speaking and swallow- 
ing. The raising of the arm increased the pain. I first fixed the shoulders 
with a figure-of-8 bandage as firm as could be borne. I then placed a roller on 
the axilla, and fixed another roller over the sterno-clavicular articulation, so as 
to retain the clavicle. A few turns of the bandage were then used to fix the 
arm on the chest, as is generally done in cases of fractured clavicle, and the 
whole was then encased in starched bandages. In a little over three weeks 
these were removed and it was found that the clavicle had become once more 
firmly fixed to the sternal articulation, and after wearing the arm in a sling for 
two weeks the patient resumed work. Now the articulation is as strong as ever.] 

Causes. — The accident seems to have been produced, in all the cases, 
so far as can be ascertained, by a force operating upon the end and top 
of the shoulder ; in consequence of which the head of the clavicle is 
pushed and at the same time lifted, as it were, from its socket, tearing 
not only its capsule with the ligaments which immediately invest the 
capsule, but also in some instances the costo-clavicular ligament with 
some fibres of the subclavian muscle. The sternal end of the clavicle is 
found riding upon the top of the sternum, its head being placed between 
the sternal fasciculus of the sterno-cleido-mastoid muscle on the one hand, 
and the sterno-hyoid muscle on the other. In one of the cases seen by 
Malgaigne, the head had traversed in this direction completely the intra- 

1 Shaw, Med. Record, Aug. 18, 1877. 

2 Vanvert, Sew York Med. Journ., March, 1879, p. 329. 

3 Rochester, Buffalo Med. Journ., vol. xiv. p. 262. 

4 Austral. Med. Gaz., 1885. 



550 DISLOCATIONS OF THE CLAVICLE. 

clavicular space, and lay behind the sternal portion of the opposite sterno- 
cleido-mastoid muscle. 

[Dr. Blodgett 1 reports an upward dislocation which occurred while a man was 
carrying one end of a piano, at the moment when the men carrying the other end 
let it fall ; he felt a sharp pain at the root of the neck and front of the chest ; 
the clavicle was luxated upward and inward, and the first and second costal 
cartilages of the same side were dislocated from the sternum forward and up- 
ward.] 

Symptoms. — The symptoms are, a depression of the shoulder, with an 
elevation of the sternal end of the clavicle so as to increase sensibly the 
space between it and the first rib. The clavicle also encroaches more or 
less upon the supra-sternal fossa, occasioning a corresponding diminu- 
tion of the space between the end of the shoulder and the centre of the 
sternum. The sternal portion of one or both of the sterno-cleido-mastoid 
muscles may also be seen raised and rendered tense by the pressure of 
the head of the bone from behind. 

Treatment. — Reduction has been found easy, but Malgaigne thinks a 
perfect retention impossible — at least it does not seem to have been ac- 
complished in any of the cases reported. In no case did the displacement 
seriously impair the functions of the arm. The same apparatus to which 
I shall give the preference in cases of dislocation upward of the acromial 
end of the clavicle, at least with only such slight modifications as the 

Fig. 349. 




Dislocation of the sternal end of the clavicle upward. 



peculiarities of the case will naturally suggest, will be suitable for this 
accident. The shoulder must be lifted by a sling, while the sternal end 
of the clavicle is pressed downward by a pad and bandages ; and all the 
muscles of the arm and chest, so far as is consistent with respiration and 
comfort, must be maintained in a state of perfect rest until the ligaments 
have become reunited. 

Dislocations of the Sternal End of the Clavicle Backward. — Two 
forms of the accident have been described ; one in which the head of the 
clavicle is driven backward and a little downward, and another in which 

1 New York Med. Journ., 1883, vol. xxxviii. 



STERN-O-CLAVICULAK. 551 

it is displaced directly backward, or backward and a little upward. In 
both of these classes, the end of the bone falls inward toward the oppo- 
site clavicle, and occupies a space in the cellular tissue back of the sterno- 
hyoid and sterno-thyroid muscles, and in front of the oesophagus ; the 
trachea, if reached at all, being probably thrust to the opposite side. 
The examples in which it has been found below the top of the sternum 
are much the most numerous ; indeed, it is probable that the other form 
is only a secondary displacement, occasioned by the action of the fibres 
of the sterno-cleido-mastoid muscle. 

The first case upon record of this kind of accident, caused by violence, was 
published by Pellieux, in 1834, in the Revue Medicate; until which time its 
existence had been generally denied. In the London and Edinburgh Journal of 
Medical Science for October, 1841, several cases are mentioned. 

Causes. — Of the eleven examples mentioned by Malgaigne, four were 
occasioned by direct blows, and most of the remainder by crushing acci- 
dents, as by powerful lateral compression of the shoulders. One of the 
cases produced by a direct blow was accompanied with an external 
wound, and is the only instance of a compound dislocation of this kind 
which I have found upon record. 

The man was admitted into St. Thomas's Hospital in September, 1835, and, 
according to his own account, the sharp end of a pickaxe had been driven through 
the flesh against the bone. The sternal end of the clavicle was found to be dis- 
placed backward, and with the finger thrust into the wound on the front of the 
chest, it could be felt resting upon the side and front of the trachea, where it 
interfered somewhat with respiration and deglutition. He had a great desire to 
congh, with a sensation of pressure on his windpipe, which was greatly increased 
when his head was thrown back. There was a slight emphysema in the region 
below the collar-bone and over the top of the sternum. The shoulder having 
been brought back with straps attached to a back-board, the bone readily resumed 
its place. The elbow was then brought forward and bound to the side, and the 
wound being closed with adhesive plaster, he was put to bed with the shoulders 
much raised. No unfavorable symptoms followed, and in three weeks he left his 
bed. Three weeks later he left the hospital with the sternal end of the bone still 
falling a little backward, and rather more movable than natural. 1 

The following example, related by Morel-Lavallee, will illustrate the class in 
which the dislocation results from an indirect blow, or from a crushing accident. 
L., 17 years old, had his right shoulder violently pressed against a wall by a 
carriage. He experienced at the moment some pain at the bottom of his neck, 
and a great sensation of suffocation, which lasted for more than a quarter of an 
hour. The dyspnoea gradually subsided, but the motion of the right arm not 
returning, he, on the eighth day after the accident, entered La Charite. On 
examination, the two shoulders were found to be on the same level, but the right 
one was nearer the median line. The internal extremity of the clavicle was half 
concealed behind the sternum. On depressing the shoulder, the inner end of 
the clavicle arose and disengaged itself from behind the sternum ; but reduction 
was effected by elevating the shoulder, while at the same time it was carried 
outward and backward. Desault's bandage was then applied, but as it became 
loosened Velpeau's was substituted, which kept the bone completely in position 
until the eighteenth day, when the patient was lost sight of. 2 

Symptoms. — The most constant symptoms are, the absence of the head 
of the bone from its socket, and its complete or partial disappearance 

1 South, note to Chelius's Surgery, Amer. ed., vol. ii. p. 218. 
Morel-Lavallee, Amer. Jouru. Med. Sci., vol. xxix. p. 229, 1842, from Gaz Med. 



552 DISLOCATIONS OF THE CLAVICLE. 

behind the sternum, an approach of the corresponding shoulder to the 
median line, an inclination of the head to the opposite side, elevation of 
the shoulder, pain at the bottom of the neck, impairment of the motions 
of the arm, sometimes difficulty in respiration and in deglutition, partial 
arrest in the circulation of the arm from pressure upon the subclavian 
artery, and a slight projection of the acromial end of the clavicle, noticed 
twice by Morel-Lavallee. 

Prognosis. — As in the other cases of dislocation at this point, the 
patients have generally recovered nearly the full use of their arms, even 
in one or two instances in which the reduction has never been accom- 
plished. 

Treatment. — It has not generally been found difficult to reduce this 
dislocation, nor when reduced is it so liable to become again displaced 
as are the dislocations forward ; yet in only a few instances has the res- 
toration been so complete as not to leave some deformity. In order to 
the reduction, the shoulder must be carried generally upward, outward, 
and backward ; and it may then be best maintained in position by lay- 
ing the patient on his back upon an elevated cushion, as practised by 
Tyrrell in the case related by South. To this may be added such other 
measures, differing but little from those employed in other dislocations 
of the clavicle, as are necessary to insure complete rest to the muscles. 
Of course, no pads or bands across the clavicle can be of any service in 
this case. 

[Mr. Crompton reduced a backward dislocation of the clavicle as follows: " I 
found a large, thick pair of worsted stockings, rolled up in the usual manner 
when clean, which I placed high up under the axilla, and asked the attendant 
surgeon to keep them there, and when I gave the word to press the elbow down 
closely to the side. The patient sitting, I got in the bed behind him ; now 
placing my knee on the spine between the two scapulae and my hands grasping 
the shoulders, I suddenly pulled them firmly back, and the bone as suddenly 
slipped into place." 1 ] 

§ 2. Acromioclavicular Dislocations. 

Dislocations of the Acromial End of the Clavicle Backward. — Of all 

the dislocations of the clavicle, this form is most frequent. I have met 
with it either as a partial or complete traumatic luxation forty-three 
times. The youngest subject was seven years of age, and the oldest 
sixty-three. All but two were males. 

I have seen one example of congenital complete upward and outward disloca- 
tion of the acromial end, which was not traumatic — the case of M. A. H., who 
was examined by me February 8, 1876, when she was four weeks old. The 
labor had been easy and natural, and there was no soreness over the joint. It 
was easily reduced, but could not be maintained in place. 

Causes. — It is produced generally by a fall upon the extremity of the 
shoulder. Twice the blow has been received rather upon the back than 
upon the extremity, and once it was occasioned by the fall of a board 

1 Guy's Hospital Eeports, xliv. 1887. 



ACROMIOCLAVICULAR DISLOCATIONS. 553 

directly upon the top of the shoulder, and once by a bolt thrust directly 
up from under the clavicle. 

Symptoms. — When the dislocation is complete, the clavicle not only is 
lifted from its articular facet to the extent of the breadth of the bone, but 
it is pushed more or less outward over the top of the acromion process ; 
generally less than half an inch, but I have once seen it riding the process 
to the extent of three-quarters of an inch. In this last example, the case 
of J. M., a strong, healthy, laboring man, the clavicle was easily reduced, 
and it always went into place with a sensible click ; but although every 
possible care was taken to retain it in place by bandages, compresses, an 

Fig. 350. 





Dislocation of the acromial end of the clavicle. 

axillary pad, and a sling, yet it was not accomplished, and on the third 
day he removed all the dressings, and refused to have them reapplied. I 
have usually found the shoulder slightly depressed ; and in one instance, 
where it is probable the deltoid muscle had suffered some injury, the elbow 
hung away from the body, and any attempts to lay it against the side 
produced an acute pain in the shoulder. 1 It has been noticed also, in 
most cases, that the clavicular portion of the trapezius muscle appeared 
lifted and tense, especially when the neck was straight. 

Inability to raise the arm to a right angle with the body is a general 
but not constant symptom. In two instances, where the displacement 
was only moderate, the patients were at first and for some time afterward 
unable to lift the arm in any degree from the side. In one example, a 
lady sixty years of age had fallen upon her shoulder and produced a dis- 
location upward, but she had not consulted a surgeon until she called 
upon me, five months after the accident. The clavicle was then raised 
from its socket about half an inch, but it could be easily pressed back to 
its place, the reduction being attended with a grating sensation, a cir- 
cumstance which I have not noticed in any other instance. She was not 
even then able to raise her arm to her head, nor had she been able to do 
so since the accident occurred. In all the motions of the arm and shoul- 
der, the clavicle is seen to move more freely than natural immediately 

1 Report on Dislocations, by the author. Transac. of New York State Med. Soc, 1855. 
p. 19, 



554 DISLOCATIONS OF THE CLAVICLE. 

under the skin, and these motions are usually attended with some pain 
at the point of dislocation. 

[Bryant describes this dislocation as that of the scapula. He says it seems 
only consistent with common sense, although not with custom, to follow Skey, 
Maclise, and Flower, and call what has hitherto been described as dislocations 
of the acromial end of the clavicle, dislocations of the scapula.] 

This accident has been sometimes mistaken for a dislocation of the humerus, 
but, unless the shoulder is already greatly swollen, the error is not likely to 
happen. If the point of the acromion process can be made out, it will be easy 
to determine, by sliding the finger along its spine, whether the clavicle is dis- 
placed or not, and by these means to settle the question of its complicity in the 
accident. The question as to whether the shoulder is dislocated or not may be 
more difficult of solution, as we shall hereafter have occasion again to observe. 

Pathology. — Generally there exists simply a rupture of the ligaments 
immediately investing the joint, so that the clavicle rises from its socket 
only about half an inch, more or less, according to its diameter, and is 
carried outward just sufficiently far to allow it to rest upon the upper 
margin of the acromial articulation. In at least thirty of the cases seen 
by me this has been the position of the acromial end of the clavicle, and 
for its complete reduction nothing more has been required than to press 
with moderate force upon the upper and outer end of the bone. In nine 
cases I have found the bone not only thus lifted on its socket, but also 
driven over upon the acromion process from half to three-quarters of an 
inch. 

In one instance, that of a gentleman, Mr. B., who was injured in a railroad 
accident, the acromial end of the clavicle was displaced outward half an inch, 
and backward three-quarters of an inch, while the sternal end also was consid- 
erably lifted in its socket and slightly sent inward. The shoulder fell forward 
and the coracoid process was one inch nearer the sternum than the same process 
upon the opposite side. In such cases more or less of the fibres of the coraco- 
clavicular ligament must have suffered a disruption ; indeed, without a rupture of 
its external fasciculus, which anatomists have called the trapezoid ligament, such 
dislocation cannot take place. M. Nicaise 1 has reported a case analogous to the 
above, in which he was unable to effect reduction ; and he has added the results 
of his own experiments upon the cadaver, which confirm the statement already 
made by me, that this dislocation cannot take place without a rupture of the tra- 
pezoid ligament. 

Prognosis. — It is impossible for me to say what has been the precise 
result in all the cases which I have seen, but my notes furnish only two 
cases of perfect retention after a complete dislocation at this point. 

One of these, D. T., aged about 25 years, fell sideways upon the ground, 
striking upon the extremity, and, as he thinks, a little upon the top of the 
shoulder. The clavicle was dislocated upward and outward, so that it over- 
lapped the acromion process half an inch. It was easily replaced, and having 
applied my own apparatus for broken collar-bones, with the addition of a band 
across the shoulder and under the elbow to keep the clavicle down, I succeeded 
in retaining the bone in place, This dressing was continued until the forty- 
second day, when, on being removed, the clavicle was seen to be closely confined 
upon its articulation ; and after a lapse of two years it still retains its position 
so completely that no difference can be detected between the opposite articu- 
lations. 

1 Nicaise, The Lancet, Oct. 14, 1876, vol. ii. p. 535. 



ACROMIO-CLAVICULAK DISLOCATIONS 



555 



In the case of Moran, already mentioned, whose clavicle overlapped the 
acromion process three-quarters of an inch, and who threw off the dressings at 
the end of three days, the same degree of displacement existed at the end of two 
years ; the scapular end of the clavicle moving freely in every direction under 
the skin according as the arm was moved. In lifting, he says, the strength of 
his arm is undiminished until he raises the weight nearly to a level with his 
shoulders, and from this point upward he can lift but little. For a laboring 
man it amounts to a serious maiming. 



Fig. 352. 



Fig. 353. 





Dislocation of the acromial end of the 
clavicle upward. 



Dislocation of the acromial end of the 
clavicle upward and outward. 



I have seen the same loss of power in the arm to raise bodies above 
the head in at least two or three of the examples of less complete dislo- 
cation, continuing after the lapse of several years ; but in the majority 
of cases, although the bone does not remain reduced, the patients have 
recovered eventually the complete use of the arm in whatever position it 
may be placed. 

The case to which I have already referred as having been caused by a bolt 
thrust upward under the clavicle, will furnish the best illustration of this general 
principle. James O'Brien, 1st U. S. Artillery, was injured in September, 1862, 
by being run over by a horse-car. A bolt, three-quarters of an inch in diameter, 
was driven through the skin on the anterior margin of the left axilla, breaking 
the first rib, severing the coraco-clavicular ligaments, and forcing the clavicle 
upward from its socket. No attempt at reduction was ever made. When seen 
by me one year after the accident, the outer end of the clavicle was lifted directly 
up two inches from the acromion process, to which it was united only by a long 
and slender ligament. He was not conscious of any loss of power or limitation 
of motion in the injured arm. At my request, my son, then in the U. S. service, 
instituted a series of experiments to test the relative strength of the two arms, 
and with the following result : First with the right arm, and then with the left, 
he lifted from the ground fifty-six pounds and three ounces, and sustained this 
weight above his head thirty seconds, with his arms fully extended. With his 
right arm extended at full length, at right angles with his body, he sustained 
twenty-five pounds for fifteen seconds. With the left arm he sustained the same 
weight, in the same position, seventeen seconds. 1 



1 Amer. Med. Times, Oct. 24, 1863. 



556 DISLOCATIONS OF THE CLAVICLE. 

Treatment. — When the bone simply rises upon its socket, the reduc- 
tion is always easily accomplished by pressing firmly upon its extremity 
with the fingers ; but if, at the same time, it has been carried outward, 
or outward and backward, the reduction is only accomplished by pulling 
the shoulder backward, or by placing a pad in the axilla, using the arm 
as a lever, or by lifting the arm by the elbow and at the same time press- 
ing the clavicle down ; and it will sometimes require the application of 
all or several of these procedures at the same moment. In some cases 
the complete reduction has only been effected when the patient has been 
brought under the influence of an anaesthetic. 

As to the maintenance of the bone in its socket for a length of time 
sufficient to insure a firm and close union of the torn ligaments and cap- 
sule, this will be found always more difficult, and in a great majority of 
cases absolutely impossible. Nearly all surgeons who have written 
upon this subject have made the same observation ; and if occasionally a 
new apparatus in the hands of a clever surgeon has seemed to promise 
better results, the same apparatus in the hands of other equally clever 
surgeons, and under circumstances equally favorable, has been found 
almost constantly to fail ; and we have been compelled again to exercise 
anew our ingenuity, and to seek for new resources, or to abandon the 
effort in despair. 

The chief obstacle to the retention of the bone in place is the powerful 
action of the trapezius, which constantly tends to elevate the outer end 
of the bone. In some measure this may be overcome by elevating very 
forcibly the shoulder, or by inclining the head, but both of these posi- 
tions are extremely fatiguing, and will not be long endured. 

Dr. Folts, of Boston, believed that he had found in Bartlett's apparatus for 
broken clavicles, modified by the application of a shoulder-strap, the infallible 
remedy for this one of the many sad defects in our art. The most important 
part of this dressing, according to Dr. Folts, is the compress placed upon the 
upper and outer end of the clavicle, and the bandage or strap passed over the 
compress and under the point of the elbow. 1 Dr. Folts is no doubt correct in 
regarding this strap as an important if not the essential part of the apparatus ; 
and it is surprising that by Sir Astley Cooper, as well as by many other expe- 
rienced surgeons, its value should have been overlooked. 

The bandage or strap, adjusted in the manner which Dr. Folts has recom- 
mended, is the only means of counteracting the action of the trapezius, upon 
which any substantial reliance can be placed ; but the principle has long been 
understood and practised upon. Brasdor's tourniquet, or Petit's, secured by a 
strap brought under the point of the elbow, Boyer's double shoulder-straps, and 
Desault's third bandage, all aimed at the accomplishment of the same purpose; 
yet Boyer and Desault found all these contrivances fail in a majority of cases. 
Mayor employed a dressing constructed with a strap to buckle over the dislo- 
cated clavicle ; but Nelaton has seen this apparatus fail also, when applied in 
his own wards. 

The experience of Dr. Folts at the time of his report did not extend beyond 
three cases, and the apparatus had been completely successful in only two of the 
three. My own experience is sufficient to show that it will be found occasion- 
ally, but by no means constantly, successful. I have already mentioned two 
cases in which I succeeded perfectly by this mode, but in several others which 
seemed equally favorable I have met with partial or complete failures. 

1 Folts, Boston Med. and Surg. Journ., vol. liii. p. 259. 



AC ROM 10- CLAVICULAR DISLOCATIONS. 



557 



The source of error, generally, on the part of those who think that 
they have devised an apparatus, or a method by which they can always 
or generally succeed in holding the bone in place until the ligaments are 
reconstructed, is, first, that they have not sufficiently noted how slight 
is the elevation, or projection, in a large majority of cases, before any 
dressing is applied, so that finding eventually very little projection, they 
call it perfect ; second, that they examine the shoulder, to determine 
whether the restoration is complete, too soon after the apparel is re- 
moved, when a very slight remaining effusion into, and induration of the 
adjacent tissues, render it impossible to say what has been accomplished; 
and third, they have sometimes had under treatment too small a number 
of cases to entitle them to form a just conclusion as to the general value 
of their method of treatment. 

The practical difficulties are, the sensibility and consequent inability 
sometimes of the point of the elbow to bear the requisite pressure, and 
the even greater sensibility of the 

skin over the top of the clavicle ; FlG - 354 - 

the tendency of the bandage to 
slide off from the shoulder, and 
also to become displaced from the 
end of the elbow ; the gradual re- 
laxation of the bandages, which, 
when existing even in the most 
inconsiderable degree, is sufficient 
sometimes to allow the bone to 
slip out from its shallow socket ; 
the impossibility of fixing the 
scapula, upon whose immobility 
as well as upon the immobility 
of the clavicle the retention de- 
pends ; and, finally, the great 
length of time requisite to unite 
firmly the ligaments, if indeed 
they ever again become actually 
united. 

The band can be prevented in 
some measure from sliding off 
from the clavicle by a counter- 
band attached to a collar upon the opposite shoulder, but not without 
causing some pain, and giving rise to excoriations generally in the oppo- 
site axilla ; and, in a degree, all the other difficulties may be met by 
patience and ingenuity, but unfortunately the smallest failure in any one 
of these numerous indications insures defeat. 

The axillary pad employed as a fulcrum upon which extension may be 
made is equally as dangerous here as in fractures, and I do not think it 
ought ever to be used for this purpose, but only as a means of moderate 
support and retention ; indeed, it would be well, perhaps, if it were dis- 
carded altogether. 




Mayor's apparatus for dislocated clavicle. 
(" Triangle cubito-bis-scapulaire.") 



558 DISLOCATIONS OF THE CLAVICLE. 

[Dr. Powers, 1 of New York, applied the following dressing successfully : The 
upper end of the arm being firmly grasped, the humerus could be used as a lever 
on which to pry the shoulder up and out; the 'dislocation being thus reduced, a 
small, firm pad was placed over the outer end of the clavicle ; a strip of rubber 
plaster, three inches in width, was then applied beneath the flexed elbow and 
carried up to the back of the arm over the outer end of the clavicle to the front 
of the chest ; then up the front of the arm and over the clavicle to the back of 
the chest. The elbow was placed against the chest and a roller bandage carried 
around the body. 

Dr. Pilcher, of Brooklyn, succeeded with the following bandage : A loop of 
one end of a bandage two inches wide, was placed around the middle of the 
forearm, and then passing the bandage directly up and over the acromial end of 
the clavicle, where a few folds of bandage had already been placed to serve as a 
compress. Thence the bandage was carried diagonally downward, and across 
the back. Continuing straight around the body until, having encircled the trunk, 
it reached again the middle of the back ; it was then slipped under the first line 
of bandage and brought back upon itself again to the front, by this manoeuvre 
forming a loop around this first bandage and securing it from slipping from its 
proper place. In bringing the bandage to the front, after having been thus 
looped around the back bandage, it was made to pass under the elbow and thence 
directly upward in front over the point of injury again ; thence it followed the 
line of the course of bandage across the back and about the body, this time pass- 
ing outside of the arm at its middle, so as to bind it to the side, thence it was 
again passed around the body and over the arm, but then was made to return 
about the elbow, from behind forward, and then upward in front once more over 
the loose acromial end of the clavicle to the middle of the back, where it was 
secured by a pin. 2 ] 

The case of Mr. B., already quoted, with a dislocation outward and backward, 
affords not only an illustration of the inefficiency of either the shoulder-strap or 
the axillary pad in certain cases, but also, it seems to me, of the mischief which 
may result from their too diligent application ; for I cannot persuade myself but 
that most of the maiming in this case was due to the apparatus rather than to 
the original accident. This gentleman was injured on the 10th of November, 
1855. A sling with an axillary pad and bandages was immediately applied. I 
saw him on the seventeenth day. The displacement was then such as I have 
described, but I did not observe any paralysis or emaciation of the limb. Having 
noticed that the clavicle fell into its socket when he lay upon his back in bed, 
at my suggestion all the dressings except the sling were removed, and the patient 
laid upon his back in bed, with instructions to continue in this position, if possi- 
ble, until the cure was complete ; but after a few days I received a communica- 
tion from his physician, stating that, owing to a troublesome cough, he had 
found it impossible to maintain this position. His residence was forty or fifty 
miles from town, and I sent him one of my dressings for broken collar-bones, 
with instructions as to its use ; directing especially that a shoulder-strap should 
be used to keep the clavicle down. The dressing was applied and continued six 
weeks, and on being removed, the elbow, wrist, and finger-joints were found to 
be stiff. The whole arm was emaciated and almost powerless. One year later 
there was no improvement in the conditton of the arm ; every joint from the 
shoulder down was almost completely ankylosed, the muscles were greatly 
wasted, and the hand trembled constantly. These results, it seems to me, were 
due to too long and too tight bandaging of the arm, and especially to the pressure 
of the axillary pad. I do not state this positively, but this is my belief. 

Is it worth while, then, to incur the dangers of too long confinement 
and of excessive bandaging for the purpose of attaining the always un- 
certain result of maintaining the bone in its socket ? We certainly may 
be permitted to make the attempt within certain reasonable limits; and 
especially if the patient is a female, and the avoidance of deformity is a 

1 New York Med. Journ., Jan. 1889. 

2 Ibid., April 10, 1886. 



ACKOMIO-CLAVICULAR DISLOCATIONS. 559 

point of serious consideration ; but never without keeping constantly in 
mind the possibility of a permanent ankylosis and paralysis of the limb. 

Dr. Gross says he first suggested the use of strong silver wire to keep the parts 
in place, and this suggestion was carried into effect by Dr. Cooper, of San Fran- 
cisco, and by Dr. Hodgen, of St. Louis. 1 Dr. Hodgen has made the operation 
twice, and both resulted well, the parts being kept well in position ; but that 
with his present experience he would not repeat the operation, except in cases 
of very great displacement. In this latter opinion, as to the circumstances under 
which alone the operation would be justifiable, I fully concur ; and even in such 
a case its propriety is questionable. 

Dislocations of the Acromial End of the Clavicle Downward. — This 
form of dislocation is exceedingly rare, only five well-authenticated cases 
are known to me as having been placed upon record, one of which was 
seen and dissected by Melle in 1765, the second was met with by Fleury 
in 1816, and the third is described by Tournel. 

Dr. W. B. Chase, of Brooklyn, N. Y., has reported a case in a boy 8 years old, 
who fell headforemost twelve or fifteen feet, striking the top of his shoulder 
upon the round of a ladder. The patient was thin, and the exact position of 
the clavicle was easily traced. The axis of the bone was changed, carrying the 
acromial end downward and a little backward. The anterior portion of the 
shoulder was flattened, and the acromion process was very prominent. He 
could move the arm slightly when it hung by his side. The boy was anaes- 
thetized, and the reduction easily effected " by throwing the shoulder outward 
and backward, while at the same time I grasped the clavicle in its outer third 
with the extremities of my fingers and thumb, and carried it upw T ard and for- 
ward into its normal position. There was no subsequent tendency to displace- 
ment." 2 Dr. Allen 3 has seen a case of dislocation downward in a boy, set. 16, 
who was in good health and vigorous. The dislocation had been caused while 
splitting wood with an axe, the arm being elevated and carried slightly outward. 
There ensued disturbance of motion and of sensibility in the arm, which Dr. 
Allen ascribed to pressure upon the nerves. Under the use of electricity these 
disturbances disappeared, and the cure was complete. 

Cause. — So far as I can ascertain, except in the case reported by Dr. 
Allen, it has been produced by a force which has acted directly upon the 
top of the clavicle. 

In the case mentioned by Tournel, a horse had trod upon the shoulder; and 
in the example recorded by Melle, the accident occurred in a child six years 
old, from an attempt to support a great weight upon the top of the collar-bone. 
In this last example the humerus was dislocated also, and both dislocations had 
remained unreduced many years when the patient was seen by Melle. 

This force acting directly upon the top of the clavicle would fail to 
dislocate the bone, except by first breaking down the coracoid process, 
if it did not happen sometimes that at the same moment the lower angle 
of the scapula was thrown outward, in such a manner as to depress 
slightly the coracoid process, and thus to permit the outer end of the 
clavicle to fall below the level of the acromion process. 

Symptoms and Pathology. — This dislocation, whether it has been pro- 
duced artificially upon the dead subject, or accidentally upon the living, 

1 Hodgen, Amer. Journ. Med. Sei., April, 1876, p. 452; Ibid., April, 1861, p: 389. 

2 Chase, Transactions Med. Soc. State of New York, 1879, p. 174. 

3 J. L. Allen, Med. Record, Feb. 19, 1881. 



560 DISLOCATIONS OF THE CLAVICLE. 

has always been found to be accompanied with a complete rupture of the 
acromio-clavicular ligaments not only, but also of the coraco-acromial 
and coraco-clavicular ligaments ; the outer extremity of the bone resting 
between the acromion process and the capsule of the shoulder-joint, and 
a little posterior to the articulating facet which originally received the 
clavicle. The superior angle of the scapula approaches the body slightly, 
and its inferior angle is thrown outward. A marked depression exists at 
the point of dislocation, accompanied with a sharp pain, increased espe- 
cially when an attempt is made to move the arm. The patient is unable 
to lift the arm voluntarily, but it can be moved pretty freely in the 
direction forward and backward by the hands of the surgeon ; abduction 
is much more difficult. 

Treatment. — Reduction is easily accomplished. At least, in all of the 
examples presented in the living subject, and referred to above, where 
the attempt was made, it was effected promptly by drawing the shoulders 
outward and backward ; nor has it been found any more difficult to main- 
tain it in position when once replaced. When the scapula is restored to 
its natural position, and its lower angle approaches again the side of the 
body, a redislocation becomes impossible; since the coracoid process now 
effectually prevents that descent of the clavicle upon which the displace- 
ment always depends. It is only necessary, therefore, to secure the 
scapula at its base and lower angle snugly to the body, by a broad band 
and compress, and all the indications of treatment are completely ful- 
filled. 

Dislocations of the Acromial End of the Clavicle under the Coracoid 
Process. — Pinjou met with one example of this singular dislocation, 1 and 
Godemer, of Mayenne, has recorded five more, 2 and these constitute the 
whole number which are at this day known to science. 

Cause. — Age and a consequent relaxation of the ligaments seem to 
constitute a predisposing cause, since of the six recorded examples four 
were between the ages of sixty-seven and seventy-one, and the other two 
were adults. In all the cases, also, the dislocations were the results of 
falls upon the shoulder. 

The symptoms which have been said to characterize this accident are 
pain and a very marked depression at the point of displacement, with a 
corresponding projection of the acromion and coracoid processes ; a rapid 
inclination outward and downward of the line of the clavicle, its outer 
extremity being felt in the axilla ; the corresponding shoulder depressed 
and inclined forward ; freedom of motion in all directions except inward 
and upward ; the lower angle of the scapula thrown outward and back- 
ward ; to which Morel-Lavallee has added an actual increase of space 
between the acromion process and the sternum. 

Treatment. — Godemer reduced all the examples which came under his 
notice easily, by directing an assistant to pull the arm backward and 
outward while he himself seized upon the clavicle with his fingers, and 
disengaged it from under the process ; but Pinjou, after many efforts by 
the same method, failed completely, and the patient having left him, the 

1 Pinjou, Journ. de Med. de Lyon, Juillet, 1842, from Vidal (de Cassis;. 

2 Godemer, Eecueil des Travaux de la Soc. Med. d'Indre et Loire, 1843, from Vidal. 



ACROMIOCLAVICULAR DISLOCATIONS. 561 

clavicle was reduced the next day by an empiric. Vidal (de Cassis) 
recommends that instead of pulling the arm outward, by which procedure 
the pectoralis major is made to antagonize the surgeon, the elbow shall 
be brought down to the side, and kept there by the left hand, while the 
right hard, placed in the axilla, shall pull the upper end of the humerus 
outward, converting the arm into a lever of the third kind. This process, 
I confess, seems to be much the most rational. 

The author will scarcely have performed his duty as a faithful writer if he 
does not state frankly that he entertains a suspicion that both the gentlemen 
who have reported these curious examples have entertained us with fabulous or 
imaginary stories ; and especially do these suspicions rest upon the cases reported 
by Godemer, who in five years saw five cases, each presenting throughout the 
same class of symptoms, the same facility of reduction, accomplished by the 
same means, and always with the same perfect result. If to these singular coin- 
cidences we add the fact that only one other surgeon has ever claimed to have 
met with the accident, and if we notice the actual anatomical difliculties which 
stand in the way of its occurrence, such especially as the complete occlusion of 
the subcoracoidean space by the tendons and muscles which pass from its ex- 
tremity toward the chest and arm, we shall find a fair apology for some degree 
of scepticism. 

Dislocations of the Clavicle at Both Ends, simultaneously. — [This 
dislocation usually results from severe injury, but in one case it occurred 
from so slight a cause as the effort of the patient to wash the back of her 
neck (Haynes). The sternal end has always been dislocated forward, 
but the acromial end has assumed various positions, though the luxation 
backward is the more frequent displacement. Reduction has been 
effected, when possible, by drawing the shoulder backward, and mani- 
pulating both extremities of the bone in such manner as to force them to 
their respective articulations. In several cases it was found impossible 
to reduce both ends, and retain them. The appliance must be some 
modification of that used in dislocations and fractures of the clavicle. 
The following detail of cases will afford useful suggestions.] 

On the 26th of January, 1863, Dr. North, of Brooklyn, N. Y., was called to 
see a lad fourteen years of age, who had been thrown with violence backward 
from a stool upon which he was sitting, striking the back of his left shoulder 
against the floor. Dr. North found him suffering severely from pain, and with 
some difficulty of breathing. The shoulder was depressed and thrown forward. 
The sternal end of the clavicle, turned forward, formed an abrupt, rounded 
prominence; the acromial end, turned forward also, presented its longest 
diameter toward the surface, and rested above the acromion process ; while the 
central portion seemed depressed or thrown back, an appearance which was 
caused by the rotation of the clavicle upon its axis. Reduction was accom- 
plished by throwing the shoulders forcibly backward, and at the same time 
pressing with the thumbs upon the two extremities in such a manner as to 
reverse the rotation, as follows: pressing at the acromial end backward and 
downward, and at the sternal end backward and upward. The restoration was 
complete, and the bones were retained in place by compresses and adhesive 
plaster, with the aid of Day's "neck yoke.'' At the end of three weeks the 
dressings were removed ; and when last seen by his surgeon '* there was but 
little, if any, trace of the accident remaining." It is the opinion of Dr. North 
that the rotation was caused by the action of the pectoralis major and deltoid 
after the dislocation took place. 1 Erichsen says that Richerand and Morel- 

1 N". L. North, M.D., New York Med. Record, April 16, 1866. 
36 



562 DISLOCATIONS OF THE CLAVICLE. 

Lavallee have each reported one example of double dislocation of the clavicle. 
Another example has been reported by Dr. Col. 1 In a case observed by Lund, 2 
and reported by Jones, the patient, a man 32 years of age, was struck on the 
posterior portion of the right shoulder, dislocating the sternal end of the right 
clavicle forward, and the acromial extremity upward and backward. It was 
found impossible to reduce the dislocation except under the influence of an 
anaesthetic. In a few days the functions of the arm were completely restored. 
Eombeau s met with a similar case, which is reported by Gros. The dislocation, 
having been first recognized several days after the accident, was reduced and 
maintained by an apparatus similar to that of Desault, which remained in place 
five weeks. Ultimately the patient recovered with slight remaining deformity, 
and with the motions of the arm completely restored. 

Dr. Stanley Haynes, of Malvern Link, has reported the only remaining case 
of which I have been able to find a record : "A girl, aged 13, rapidly growing, 
of lax tissues, and of a consumptive family, but who had always had good health, 
while washing the back of her neck with her left hand, one morning in Septem- 
ber, felt something give way in the shoulder of the same side. I found disloca- 
tion forward of the sternal end of the clavicle and partial dislocation upward of 
the acromial one. There was very little pain. Both extremities of the bone 
were easily replaced by drawing the shoulder backward and downward, but the 
double deformity was reproduced immediately the shoulder was liberated. A 
pad was applied under a figure-of-8 bandage over the sternal end, and the arm 
was placed in a sling as a temporary measure. To a strap, fastening round the 
chest, a strap bearing a truss-pad was attached in such a manner that the pad 
kept the sternal end of the clavicle reduced, the other end of the strap passing 
over the shoulder and diagonally across the back to the horizontal strap : the 
wearing of a sling kept the acromial end in its natural position. The patient 
soon afterward returned to school at a distance. She is now at home, and I have 
found the sling has been discontinued some time ; that the straps have stretched 
and are useless; and that the ends of the bone are as mobile as, but not more 
than, they were when I first saw the patient, but that the sternal end does not 
become dislocated unless the arm is raised, when it nearly always starts for- 
ward." 4 

[Mr. Hulke, of London, reports the following case : A woman was struck on 
the left clavicle by the knee of a horse, and as a result both ends of that bone 
were dislocated. The left shoulder had fallen inward and forward, and the head 
was inclined toward the left side ; the sternal end rested on the upper part of 
the anterior surface of the manubrium sterni, forming a marked projection under 
the skin ; the acromial end was displaced backward and inward, resting on the 
scapular spine opposite its junction with the acromial process. The long axis of 
the bone was placed in an antero-posterior, rather than in the normal transverse, 
direction. Both the manubrial and the acromial articular facets could be plainly 
felt as concavities beneath the skin. By drawing the shoulders backward the 
bone slipped easily into position, but on relaxation luxation immediately re- 
curred. The reduction was maintained by a gutta-percha splint fitted to the 
shoulder and reaching past the point of the sternum in front and maintained by 
a bandage. 

Mr. Newman reports the case of a laborer who was injured in the fall of a 
building, receiving among other injuries two fractures of the left clavicle and a 
dislocation of both ends of the right clavicle — the sternal end was elevated and 
the acromial end depressed. No efforts were made at reduction, owing to other 
injuries, and he soon passed from observation. 5 ] 

1 Col, Gaz. des Hopitaux, 1872, p. 893. 

2 Lund, Brit. Med. Journ., 1874, No. 682, p. 106. 

3 Rombeau, Bull. Gen. de Therapeutique, 1874, vol. lxxxvi. p. 537. 

4 The British Medical Journal, Jan. 27, 1872. 

5 London Lancet, Sept. 19, 1885. 



DISLOCATIONS OF THE SHOULDER. 563 



CHAPTEE VII. 

DISLOCATIONS OF THE SHOULDER (SCAPULO-HUMERAL). 

Owing to the great exposure and the peculiar anatomical structure 
of the shoulder-joint, its structure having reference mainly to freedom 
of motion rather than to firmness and security in the articulation, dislo- 
cations of the humerus are very common. 

My private and hospital records furnish me with 117 cases of dislocation of 
the shoulder, seen and recorded by myself. Of these, 41 were recognized as 
subglenoid, 33 as subcoracoid, a very small proportion as subclavicular, 2 as 
subspinous, and the remainder were not accurately diagnosticated. 

Writers have not been agreed as to the precise anatomical relations of these 
dislocations, nor as to the nomenclature. Velpeau, Malgaigne, Vidal ( de Cassis), 
Skey, and Sir Astley Cooper have each adopted explanations and classifications 
peculiar to themselves. With the arrangement established by this latter sur- 
geon English and American students are the most familiar ; and believing that 
it is more simple, and quite as appropriate as either of the others, I shall adopt 
it as the basis of my own descriptions. 

According to Sir Astley Cooper, there are three complete dislocations 
of the shoulder ; namely, downward, forward, and backward. The so- 
called " suipra-coraeoid" dislocation, without a fracture of the coracoid 
or acromion processes, the possibility of which has been denied by Boyer, 
but examples of which are declared to have been seen by Malgaigne, 
Holmes, Hewitt, have now sufficient affirmative testimony to justify me 
in devoting a section to its consideration. 

[The classification of dislocations at the shoulder, herein given, is wanting in 
scientific precision, as well as in exact pathological conditions. Flower and 
Hulke [System of Surgery) well remark: "As want of precision in the terms used 
in describing varieties of luxation has hitherto been a principal source of 
obscurity, it will be necessary, before proceeding further, to adopt a definite and 
intelligible system of nomenclature. The obliquity of the glenoid fossa, and the 
variations in the position of the scapula, render such words as downward, for- 
ward, inward, etc., very inefficient as distinctive designations of particular forms 
of dislocation. Names derived from the relation of the head of the bone to its 
new situation to important contiguous osseous structures are more concise, 
expressive, and definite." 

Acting upon these opinions, they find that all the possible dislocations of the 
humerus readily group themselves into the following subdivisions : 

1. Subcoracoid. — Forward and slightly downward; upon the neck of the 
scapula, in front of the glenoid fossa, and immediately below the coracoid pro- 
cess. Common. 

2. Subglenoid. — Downward and forward; head of the humerus in front of the 
inferior costa of the scapula, below the glenoid fossa. Rare. 

3. Subclavicular. — To the inner side of the coracoid process, under the clavicle. 
Very rare. 

4. Supracoracoid. — Upward and forward ; upon the fractured coracoid process. 
Only three cases reported. 

5. Subspinous. — Backward ; upon the back of the neck of the scapula, beneath 
the spine or posterior edge of the acromion. Very rare. 



564 DISLOCATIONS OF THE SHOULDER. 

Of these different dislocations, Mr. Flower regards the subcoracoid as the most 
common, while other authorities make the subglenoid most frequent. This dis- 
crepancy arises chiefly from the inaccuracy of the terms downward and forward ; 
many dislocations classified under the old nomenclature as subglenoid, or down- 
ward, were, in fact, subcoracoid.] 

Dislocations of the Shoulder Downward (Subglenoid). — This is usually 

called a dislocation into the axilla ; the head of the bone resting rather 

upon the inner side of the inferior border of the scapula, near the base 

of that triangular surface which is found below the glenoid fossa. Since 

in both the other complete dislocations of the shoulder the head of the 

humerus, in order to escape from its socket, must be made to descend 

more or less downward, jT shall regard this dislocation as the type of all 

the others, and shall make it the subject of especial consideration, as 

well as of reference, when speaking of the other forms of dislocation. 

Causes. — The most frequent cause of this accident is a blow received 

directly upon the upper end and outer surface ot 

FlG - 355. the humerus. I have found the arm dislocated 

into the axilla by this cause thirty-one times ; five 

times by a fall upon the extended hand ; three 

times by a fall upon the elbow ; and in these latter 

cases the arm was probably carried away from the 

body at the moment of the receipt of the injury. 

In all the above examples the shoulder has been 

dislocated by the simple force of the blow, or with 

only slight aid from muscular action ; but in a 

considerable number of cases the bone is displaced 

almost wholly by the action of the muscles, the 

arm having been previously violently abducted ; 

Subglenoid dislocation. and perhaps in some cases the capsule being torn 

before the resistance of the overstrained muscles 

has accomplished the displacement. Thus, in three instances I have 

known the dislocation to result from holding on to the reins after being 

thrown from a carriage ; in two cases the patients have fallen through a 

hatchway and been caught and suspended by the arms : once a woman 

met with this accident by holding on to a pump-handle when she had 

slipped and fallen upon the ice. 

A few years since I examined the arm of a Swiss woman, Maria Norregan, 
who was then sixty-five years old, and whose humerus had been dislocated into 
the axilla seventeen years before, where it still remained. Her own account of 
the accident was, that she was returning from the Jura Mountains, near Neuf- 
chatel, with a load of hay upon her head. She had carried it a long way with 
her hands held upward, without once stopping to rest, and when at length she 
threw down the load at her door, the right shoulder was dislocated. The arm 
soon became very painful, and swollen to the fingers' ends; but she was too 
remote from, and too poor to employ, a surgeon. A tailor, who used to do the 
minor surgery of the neighborhood, bled her three or four times, but the dislo- 
cation was not recognized until many months after. A Mrs. Hunn informed me 
that when she was twenty-two years old she had a convulsion, and that her 
attendants in trying to hold her upon her bed actually pulled the shoulder out 
of joint. After the first accident the dislocation was not repeated for four years, 
but since then it had occurred from very slight causes many times. She was in 
the habit of reducing it herself by placing a ball in the axilla and using the arm 




DISLOCATIONS OF THE SHOULDER. 56b 

as a lever. Dr. Scatliff, of Brighton, 1 Coombs, of Castle Cary, 2 and others, have 
published examples of this dislocation caused by epileptic convulsions. I have 
myself seen such examples. Dr. Lehman reports the case of a sailor on board 
an American brig, who was subject to a dislocation into the axilla from very 
slight causes, and especially if he bent his body far over to raise anything. He 
could also, by pulling horizontally, remove the head of the bone from its socket. 
It was reduced easily, and he experienced no pain either in the reduction or 
dislocation, nor, indeed, during the displacement. 3 

[Brackett, 4 of Nashua, la., reports a dislocation of the humerus into the axilla 
occurring in a child two years old ; the accident was due to the sudden lifting 
of the child by the extended arm.] 

Pathology. — In this accident the head of the bone is made to press 
against the capsule below and immediately in front of the long head of 
the triceps, until the capsule gives way, and continuing to descend in 
the same direction it is finally arrested by the triangular surface of the 
inferior edge of the scapula immediately below the glenoid fossa. Owing 
to the pressure of the tendon of the triceps behind, it occupies a position 
also a little in advance of the centre of this triangle, or rather upon its 
anterior edge, so that it rests more or less upon the belly of the sub- 
scapularis muscle. 

The capsule is generally torn quite extensively, especially below and 
in front; and the tendon of the long head of the biceps may be broken 
asunder, or detached completely from its insertion ; the supra-spinatus 
muscle is stretched or lacerated ; the infra-spinatus, subscapularis, and 
coraco-brachialis are put upon the stretch ; the subscapularis being also 
sometimes completely torn from its attachment to the head of the hume- 
rus, and in either case, whether torn or merely compressed and stretched, 
the circumflex nerve, which runs along its lower margin, is subject to 
severe injury ; the deltoid muscle is also placed in a condition of extreme 
tension ; while the teres major and minor in this respect are subjected 
to but little change. In some cases a portion or the whole of the greater 
tuberosity is completely detached, and the fragment displaced by the 
action of the muscles inserted into it. 

[Mr. Avill reports a case of dislocation of the shoulder without rupture of the 
capsule : J. B., aged 69, fell a distance of eighteen feet upon the pavement, 
pitching on his right elbow and side, producing a dislocation of the shoulder 
and a T-fracture of the elbow. He died on the twelfth day after admission. 
Post-mortem examination revealed the following : The head of the humerus was 
in its proper position in the glenoid cavity, and the capsule of the joint quite 
intact ; it seemed more lax than it normally should be, and its attachment to 
the anterior border of the glenoid cavity somewhat raised, being stripped off the 
bone to a slight extent, but still continuous with the periosteum. The coracoid 
process was torn off the scapula, but was still attached to the short tendon of the 
biceps, and all the muscles surrounding the joint were quite sound, with the 
exception of the subscapularis, which was slightly lacerated. 5 ] 

In one case the axillary artery has been ruptured. The patient had been 
thrown down by a runaway horse, and was taken to Jervis Street Hospital, 
London. On the tenth day Surgeon O'Reily tied the subclavian artery, and 
the patient recovered after the loss of two fingers from erysipelas and gangrene. 6 

i Scatliff, The Lancet, 1878, vol. i. p. 31. 

2 Coombs, Idem, p. 150. 

3 Lehman, Amer. Journ. Med. Sci., vol. i. p. 242, 1828. 
i Medical Record, Sept. 27, 1890. 

5 St. Barth. Hosp. Reports, vol. xxiv., 1888. 

6 Todd's Cyclop. Anat. and Surg., p. 616,- Holmes's Surg., vol. ii. p. 827. 



566 



DISLOCATIONS OF THE SHOULDER. 



With more or less rapidity, after the occurrence of the dislocation, if 
the bone remains unreduced, various changes take place in the anatomi- 
cal relations and structure of the parts. 

The following is a brief account of the condition in which the parts were 
found in the case of an old man, whose history is unknown. The dissection 
was made by my assistant, Dr. Deems, at the Bellevue dead-house. The head 



Fig. 356. 



Fig. 357. 




Dislocation of the shoulder downward into 
the axilla. (Subglenoid.) 



Dislocation downward, showing the untorn 
portion of the capsular ligament. (Gu'nn.) 



of the humerus was in front of the socket, below, but not in contact with, the 
coracoid process, lying upon the anterior surface of the neck of the scapula. A 
new socket was formed in the bone at this point, mostly cartilaginous, and a 
fibrous capsule inclosed the head of the humerus. The margins of the old 
socket were removed, and the socket was filled with fibrous tissue. The axillary 
nerves and artery were not injured or compressed. The biceps tendon was not 
torn. All the muscles about the shoulder were atrophied. 

Symptoms. — A palpable depression immediately under the extremity 
of the acromion process, more distinct in children, in very old, and in 
thin people, than in adults of middle life or than in fat or muscular 
people, but never absent completely, unless the shoulder is very much 
swollen : the elbow carried out from the body three or four inches, some- 
times a little backward, and the line of its axis directed toward the axilla ; 
the outer surface of the arm presenting two planes inclined toward each 
other, and meeting at the point of insertion of the deltoid muscle ; the 
head of the humerus felt in the axilla, particularly when the elbow is 
carried away from the body ; numbness of the arm, accompanied gener- 
ally with pain, especially when any attempt is made to press the elbow 
against the side ; rigidity with inability to move the arm freely in any 
direction, but especially inward ; allowing, however, of pretty free passive 
motion, but not permitting the elbow to touch the body without great 



DISLOCATIONS OF THE SHOULDER, 



567 



pain, which pain is occasioned mostly by the pressure of the humerus 
upon the axillary plexus ; under no circumstances can the hand be placed 
upon the opposite shoulder while at the same moment the elbow touches 



Fig. 35 




Appearance of dislocation of the shoulder. (Subglenoid.) 

the thorax ; the head of the patient, and sometimes the whole body, in- 
clined toward the injured arm ; the arm lengthened from half an inch to 
an inch ; a chafing or friction sound is not unfrequently present, espe- 
cially if the bone has been some days dislocated. 

Mr. Lawrence mentions a case in which there was a distinct crepitus, yet there 
was no fracture ; Dr. Hays saw a similar case in Wills Hospital, Philadelphia, 
in a woman 60 years old, whose arm had been dislocated forward eight weeks. 1 
Other surgeons have related like examples, but it is probable that in all these 
cases there has been an exposure of the bone at or near the edge of the glenoid 
fossa, by the partial detachment of its ligamentous margin, or some portion of 
the head has become divested of its cartilaginous covering. 

Decisive as these signs usually are of the true nature of the accident, 
cases will occur in which the diagnosis will be attended with great diffi- 
culty, and especially if a few hours have been permitted to elapse since 
the occurrence of the injury, so that considerable effusions of blood and 
of lymph may have taken place ; while at a still later period, when the 
swelling has subsided, the diagnosis again becomes easy. 

In a rapid review of the cases of dislocation of the shoulder which have come 
under my notice, and of which I have taken pains to make a record, I find thir- 
teen subglenoid and ten subcoracoid dislocations which were not recognized as 
such by the surgeons first called. Some were mistaken for fractures, and some 

1 Lawrence, Hays, Amer. Journ. Med. Sci., vol. xxiv. p. 236, May, 1839. 



568 DISLOCATIONS OF THE SHOULDER. 

were called contusions or sprains. And among the surgeons who fell into these 
errors are some of our oldest and most experienced hospital surgeons. 

Prognosis. — If the force which displaced the bone was not great, or 
if the shoulder-joint has not suffered any injury from the accident itself 
beyond the mere rupture of the capsule and a moderate straining of the 
muscles, and if the dislocation has been early and easily reduced, the 
patient is immediately after the reduction able to move the arm freely in 
all directions ; very little swelling follows, and in a short time a perfect 
restoration of all the functions of the limb is accomplished. It cannot, 
however, always be inferred from the degree of violence employed in the 
production of the dislocation, nor from the absence or presence of swell- 
ing, how much injury the tendons, muscles, and nerves have suffered, 
since the same causes produce greater lesions in one person than in 
another, and the amount of swelling may depend upon the accidental 
rupture of an unimportant bloodvessel, or upon some peculiarity in the 
constitution of the patient predisposing to serous, fibrous, or sanguineous 
effusions. 

To whatever cause we may find occasion to attribute the result, it will 
nevertheless be observed that, in a great majority of cases, the limb is 
not restored to all its original strength and freedom of motion until after 
the lapse of some months ; and the shoulder does not resume its perfect 
form and symmetry until a much later period ; occasional pains, espe- 
cially after exercise of the muscles, and in certain conditions of the 
weather, are present also at irregular intervals and for indefinite periods 
of time. Opposite and more favorable terminations must be regarded as 
exceptions to the rule. Where the reduction has been made within a 
few hours, I have found the shoulder affected with muscular ankylosis 
with more or less weakness of the arm after a lapse of from a few days to 
one or two years. 

A laborer, set. 41, had dislocated his right shoulder into the axilla. Dr. H., 
an intelligent young surgeon, reduced the bone easily with his hands alone, 
while the patient was still unconscious from the shock of the injury. After six 
weeks he called upon me, accompanied by his surgeon, thinking that it was not 
properly reduced because the arm was still- painful, and he could not move it 
freely. The bone was, however, well in its socket. One year later I examined 
this man, and found some ankylosis remaining in his shoulder-joint. 

J. E., set. 39, fell while running, and struck upon his right shoulder. Dr. 
Eastman reduced the dislocation four hours after the occurrence, in the fol- 
lowing manner : The patient being seated in a chair, Dr. Eastman placed his 
knee in the axilla and manipulated, while one assistant supported the acromion 
process, and another pulled downward upon the forearm. The time occupied 
in the reduction was about two minutes, and the bone finally resumed its posi- 
tion with a snap audible to all the persons in the room. For some months after, 
and at the period when 1 saw him, the muscles about the shoulder were rigid, and 
the motions of the joint embarrassed ; but at the end of two years, Dr. Eastman 
informed me that the joint had become free and the arm as useful as before, 
except that he could not throw a stone. 

In another case, a gentleman residing in an adjoining county, set. 42, was 
thrown from his carriage, falling forward upon his hands. The dislocation was 
reduced promptly, by placing the heel in the axilla, and within fifteen minutes 
after it had occurred. Three months after this the patient consulted me on 
account of the immobility of the shoulder-joint, and because several surgeons 
had expressed a doubt whether it was properly reduced. The ankylosis was then 



DISLOCATIONS OF THE SHOULDER. 569 

so complete that the humerus could not be moved separately froui the scapula, 
but there was no displacement. This gentleman again called upon me at 
the end of four years, and I then found the arm nearly restored to its original 
condition, but it was not quite so strong as before. He experienced also 
"curious" sensations in his arm and hand occasionally. The ankylosis had 
continued with very little improvement about two years, after which it had been 
gradually disappearing. 

In those examples in which the reduction of the bone has been delayed 
beyond a few hours, or for several days or weeks, the continuance of the 
ankylosis lias been more persistent ; but in no case which has come under 
my observation, unless the bone still remained unreduced, has the anky- 
losis been permanent. For this reason I am disposed to think that 
muscular, rather than fibrous or ligamentous ankylosis, is the cause, 
generally, of the immobility of the joint. I have certainly never in any 
instance met with a true bony ankylosis as a consequence of a shoulder 
dislocation. The ankylosis in question seems to be a result simply of lacer- 
ation, or more generally of a severe strain of the muscular fibres, resulting 
in inflammation and a contraction of these fibres ; and its occurrence in 
any particular case may, therefore, be justly attributable either to the 
position of the bone when it is dislocated, to the force of the blow which 
has produced the dislocation, or to the violence applied in the attempts 
at reduction. 

Paralysis and wasting of the muscles of the arm, either with or without 
muscular contraction and rigidity, are also observed in a certain number 
of cases. Especially has it been noticed that the deltoid muscle is liable 
to atrophy ; and in their attempts to explain the frequency of its occur- 
rence in this latter muscle, surgeons have generally referred to a probable 
rupture of the circumflex nerve, a circumstance which the autopsies show 
does occasionally take place ; or to a mere stretching of this nerve ; yet 
it is quite as fair to presume that in many cases it is due solely to the 
greater injury which the deltoid muscle has sustained by the unnatural 
position of the head of the bone during the continuance of the disloca- 
tion, for, with the exception of the supraspinatus, it is placed more upon 
the stretch than any other. Nor is it improbable that in some cases it 
is due to the mere force of the blow, which, having been directly upon 
the top of the shoulder, has contused the muscle. In short, any of the 
causes which may determine in the deltoid inflammation and consequent 
rigidity, must finally result in desuetude and consequent atrophy. 

In the case of an adult, P. Madden, who consulted me in June, 1874, there 
were slight atrophy and paralysis of the deltoid, and almost complete atrophy 
of the supraspinatus, with much ankylosis, due to prolonged efforts at reduc- 
tion. In quite a number of cases my attention has been called to a remarkable 
fulness just in front of the head of the bone, which has continued sometimes for 
many months and even years after the reduction has been effected ; the patients 
having in several cases applied to me to know whether this did not indicate that 
the bone was not in its socket, especially as it has usually been attended with 
some stiffness in the joint. Not unfrequently I have been told that surgeons 
who had noticed this fulness thought the bone was not reduced ; and in one 
instance I am informed that a jury returned a verdict against the surgeon, where 
there was no other evidence of malpractice than this fulness with some ankylosis, 
but which, in the opinion of some medical gentlemen who testified, was con- 
clusive evidence that the bone was not properly set. The deception is also often 
the more complete from the fact that there may exist a corresponding depression 



570 DISLOCATIONS OF THE SHOULDER. 

underneath the acromion process, behind. These phenomena may be present 
where but little force has been used, either in the production of the dislocation 
or in its reduction. I have seen it in a girl only 14 years of age, who had dis- 
located her left shoulder into the axilla, by a fall upon a slippery sidewalk. I 
reduced the bone within half an hour after the accident. I lifted the arm to a 
right angle with the body, and pulled gently, and the reduction was at once 
accomplished ; but I immediately noticed that the head of the bone seemed to 
press forward in the socket so as to resemble what Sir Astley Cooper has 
described as a partial forward dislocation. There was also a corresponding 
depression behind. Carrying the elbow back rendered the projection more 
decided, but bringing it forward did not make it entirely disappear. 

In other instances where the deformity in question has been present, 
more force has been employed in the reduction. 

A man weighing two hundred pounds, fell from a load of hay, striking upon 
the top and front of the left shoulder. It was immediately ascertained that he 
had dislocated his arm into the axilla, and broken his leg. A young surgeon 
attempted within a few minutes to reduce the dislocation, but failed ; and about 
two hours later it was reduced by another surgeon, with the aid of chloroform 
and Jarvis's adjuster. Four years after the accident this gentleman came to me 
accompanied by the surgeon who had made the reduction, in consequence of its 
having been intimated by some medical men that it was not properly reduced. 
The arm was not as strong as the other; some ankylosis existed at the shoulder - 
joint; but especially it was noticed that there remained a remarkable fulness in 
front, as if the head of the bone was pressed forward. By no manipulation or 
position could this fulness be made to disappear, yet the bone was plainly enough 
in its socket. 

This phenomenon is probably due in some cases to a rupture of the 
supraspinatus muscle, and the consequent preponderating action of the 
antagonizing muscles, or to the extensive laceration of the capsule ; but 
in others to a rupture or possibly to a displacement of the long head of 
the biceps, a circumstance to which I shall more particularly allude 
under the subject of "Partial Dislocations." Among the results of this 
dislocation must be placed a tendency to redislocation, which, although 
it may not often be made manifest by its actual occurrence, owing per- 
haps to the prudence of the surgeon, yet it does take place in a sufficient 
number of cases to establish its peculiar liability. Indeed, we need only 
consider how imperfect is the protection against this accident, when once 
the capsule has been torn, to appreciate this observation. Examples of 
spontaneous dislocation, or of dislocation of the shoulder from very trivial 
causes after it has once been dislocated, may be found in the experience 
of almost every surgeon. I have met with several persons who have had 
repeated dislocations from a slight cause, and in some instances where 
the patients were subject to epilepsy the dislocations have occurred when- 
ever the convulsions returned. 

A gentleman had a dislocation of the right shoulder into the axilla when he 
was quite a child, and the accident was renewed when 29 years old by falling 
from a carriage head-foremost, with his right arm extended and uplifted. Since 
then, a period of about six years, he has been constantly sucject to the same 
dislocation ; and he cannot raise his arm high above his shoulders without pro- 
ducing a partial dislocation, the head of the humerus resting upon the outer 
margin of the lower and anterior edge of the glenoid fossa, but by rotating the 
arm outward it immediately resumes its place. I found the whole limb as fully 
developed, and he said it was quite as strong, as the opposite limb. 



DISLOCATIONS OF THE SHOULDER. 



571 



I have already mentioned the case of Mrs. Hunn, whose arm had been dislo- 
cated more than twenty times during five years. A lad, aged 19 years, dislocated 
his left arm by falling from the masthead of a vessel, and hanging by his hand. 
No attempt was made to reduce it until fourteen hours after the accident, at 
which time it was set by two German doctors, but not until they had pulled 
upon it three hours. Four months after, it was again dislocated by the slipping 
of an oar while he was rowing a boat. A surgeon having failed this time to 
bring it into place, I succeeded readily, and without the aid of an anaesthetic, 
by raising the arm directly upward in the line of the body, while my foot was 
pressed upon the top of the scapula. Many other similar examples have come 
under my notice. 

I have referred to the writers who mention many examples of unreduced 
dislocations of the shoulder, for which surgeons of skill and experience were 
responsible. I have myself met with these cases quite often. I have seen two 
dislocations of the humerus into the axilla, both of which had been seen 
and examined by New York hospital surgeons within a few hours after the 
receipt of the injury, but the nature of the accident had not been recognized. 
One of these I reduced at Bellevue Hospital on the seventh day, and one on the 
tenth. In other cases the dislocation has been clearly made out, but the surgeon 
has been unable to reduce the bone. 

M. K., set. 49, a large, fat, laboring woman, was admitted into the Buffalo 
Hospital with a dislocation of the right humerus into the axilla, which had 
occurred twelve hours before. This is the same woman of whom I have before 
spoken as having produced the dislocation by a fall while holding upon the 
handle of a pump. Drs. Lockwood and Baker were first called, and attempted 
reduction. They made extension and counter-extension in every possible direc- 
tion, and for a long time, but to no purpose. Having placed her completely 
under the influence of chloroform, the manipulations were made assiduously 
during one hour, without success. On the following morning she was bled freely 
from the opposite arm, and chloroform again administered ; extension being 
made with Jarvis's adjuster. After more than 
an hour, the effort was again suspended. On 
the following day we made a third attempt, 
the patient being completely under the in- 
fluence of chloroform, but with no better 
success. The chloroform produced a con- 
dition approaching apoplexy, and it was not 
again used. On the tenth day, assisted by 
other surgeons, we applied the compound 
pulleys, moving the arm in various directions. 
Twice we thought the reduction was accom- 
plished, but as often we proceeded to examine 
it attentively we found it was not. If it did 
ever pass into the socket, it was immediately 
displaced. Sir Astley Cooper has thus de- 
scribed the appearances presented on dissec- 
tion . of a dislocation which had been long 
unreduced : " The head of the bone altered 
in its form ; the surface toward the scapula 
being flattened. A complete capsular liga- 
ment surrounding the head of the os humeri. 
The glenoid cavity entirely filled by liga- 
mentous matter, in which were suspended 
small portions of bone, which were of new 
formation, as no portion of the scapula or humerus was broken. A new cavity 
formed for the head of the os humeri on the inferior costa of the scapula; but 
this was shallow, like that from which the bone had escaped." 

When the dislocation into the axilla remains unreduced, the conse- 
quences are always sufficiently grave ; but they differ very much in 
degree, in character, and in persistence, according as the arm has re- 



Fig. 359. 




New socket, in an ancient disloca- 
tion of the shoulder downward. (From 
Sir A. Cooper.) 



572 DISLOCATIONS OF THE SHOULDER. 

mained a longer or a shorter time unreduced, and according to the presence 
or absence of complications. These conditions will be best illustrated 
by a reference to examples. 

Wrn. S., a German, set. 51, fell down a flight of steps while intoxicated, pro 
ducing a dislocation of the left arm into the axilla. Eleven hours after the 
accident he was received into the Buffalo Hospital. No attempt had been made 
to reduce the bone. The reduction was effected by myself with tolerable ease, 
by extending the arm perpendicularly above the head, while my foot pressed 
upon the top of the scapula. The head of the humerus could be plainly felt in 
the axilla, approaching the socket, until it seemed to be directly over it, when, 
on lowering the arm, it was found to be reduced. After the reduction the 
patient could not raise the arm more than eight inches from the body. The 
fingers, hand, and forearm were almost paralyzed. Three weeks later, when he 
left the hospital, his arm had improved, but he could not flex his fingers. 

Mrs. G., set. 70, fell down a flight of steps and dislocated her arm into the 
axilla. She did not suspect the nature of the injury, and no surgeon was called. 
I was consulted one week after the accident, at which time she was suffering 
great pain from the pressure of the head of the bone upon the axillary nerves. 
We first attempted to reduce the bone by resting the knee in the axilla while 
she was sitting, but without success. We then placed her in bed, and with my 
knee in the axilla, the acromion process being supported by the hands of an 
assistant, we restored the bone after a few moments of pretty firm extension 
downward and outward. After the reduction she could not raise her arm, but 
the pain was much abated. One month later the arm remained very weak. She 
could not raise it more than six inches toward her head, but I could raise it to a 
right angle with the body without causing pain. The whole hand felt numb, 
and was occasionally painful. The deltoid muscle was slightly atrophied. There 
was also a slight flatness under the acromion process behind, and on the outer 
side, with a corresponding fulness in front. 

M. A. H., set. 47, was admitted to the hospital with a dislocation of the right 
humerus into the axilla. The arm had been dislocated three weeks, in conse- 
quence of a fall upon the upper and outer part of the shoulder. When she came 
under my notice the arm was lengthened about one-quarter or one-half of an 
inch, and hung out from the body in a condition of almost complete paralysis. 
There was very little swelling about the shoulder or arm, and the head of the 
bone could be distinctly felt in the axilla. The patient being rendered partially 
insensible by chloroform, I placed my heel in the axilla, and pulling moderately 
about thirty seconds in a direction slightly outward from the line of the body, 
the bone was reduced. Seven days after the reduction she left the hospital, the 
arm being yet quite useless, though not greatly swollen. There was also a 
striking fulness in front of the head of the bone. 

W. G., set. 75, dislocated the right humerus into the axilla, twenty years before 
I saw him, by falling upon his hands with his arm extended. I found the arm 
weak and atrophied, so that he could raise it but slightly outward from his 
side ; he was unable to move it forward much beyond the line of his body ; but 
he could carry it back quite freely. The whole hand was in a condition of par- 
tial insensibility. 

In the case of the Swiss woman, whose arm had been dislocated downward 
seventeen years, the deltoid muscle has become greatly wasted; the head of 
the bone can be felt obscurely in the axilla ; the arm is shortened perceptibly ; 
the elbow hangs freely against the side ; the little and ring fingers are numb, 
and also one-half of the forearm; the whole hand and arm are weak and atro- 
phied ; she complains also occasionally of a troublesome sensation of formication 
over the arm and hand ; she cannot straighten her fingers perfectly ; the elbow 
may be raised from the side to a right angle with the body, but she cannot 
raise it herself more than one foot ; she carries it back a little more freely than 
forward. 

In compound dislocations the prognosis must always be regarded as 
exceedingly grave. 



.DISLOCATIONS OF THE SHOULDER. 573 

In the only example which has come under my notice, the circumstances 
attending which I shall hereafter mention in the general chapter devoted to 
Compound Dislocations, the patient died from sloughing of the axillary artery. 
Mr. Scott has, however, reported a case, in a boy fourteen years of age, who 
recovered rapidly after the reduction was effected, and in thirteen months his 
arm was nearly as useful as before. 1 

Treatment. — The principles of treatment in this dislocation are very 
simple and easy to be comprehended. I speak now of recent uncompli- 
cated cases of dislocation into the axilla ; and, notwithstanding the 
various and sometimes almost contradictory views which surgeons have 
entertained as to the best and most rational modes of procedure, I con- 
tinue to affirm that the laws which are to govern the reduction in a great 
majority of cases are established and indisputable. Observe now the 
obvious anatomical facts, and then consider the inevitable inferences. 
The capsule is torn, generally extensively, along the inner and lower 
margins of the socket. The head of the bone is lodged below and slightly 
in advance of its natural position, in consequence of which the points of 
origin and insertion of the deltoid muscle and the supraspinatus are 
separated somewhat and their fibres rendered tense, insomuch that the 
arm is abducted and actually lengthened. 

At first/and in the most simple cases, these are the only muscles which 
are in a state of extreme tension, but after the lapse of a few hours, or 
of a few days, nearly all the other muscles about the joint, most of which 
were originally only in a condition of moderate extension, and some of 
which were rather relaxed than extended, sympathize with those which 
are suffering the most, and a general contraction and rigidity ensue, 
increased also at the last by the supervention of inflammation and its 
consequences. What, from these simple premises, must be the obvious 
practical deductions ? That in the simplest forms of the dislocation the 
most rational mode of reduction will be to elevate the arm sufficiently to 
relax the overstrained deltoid and supraspinatus muscles, which, together 
with the upper and untorn portion of the capsule, bind the head of the 
bone in its new position, and to pull gently in the same direction, in 
order to overcome the moderate resistance offered by several other 
muscles, but whose tension cannot be relieved by the same manoeuvre. 

Failing in this, that we shall increase the relaxation of the first-named 
muscles, by pulling at a right angle with the body, or even directly 
upward ; and meanwhile, as Ave carry the arm more and more upward, 
we shall operate more powerfully against the resistance of the other 
muscles. If in all these modifications of the same procedure except 
when drawing directly upward, we keep the arm a little back of the 
axis of the body, we shall accomplish the indications the most perfectly. 

Such are the conclusions which must be drawn from the anatomical, 
or, as Mr. Pott would call it, the " physiological," argument ; and which 
assumes as its basis that the muscles with the untorn portion of the 
capsule constitute the sole or the main obstacle to the return of the bone 
to its socket. 

1 Scott, Amer. Journ. Med. Sci., vol. xx. p. 515, Aug. 1837, from the London Lancet. 
March 4, 1837. 



574 DISLOCATIONS OF THE SHOULDER. 

It must not be forgotten that in all these modes of extension, for with nearly- 
all of them some slight degree of extension is found necessary, there must be 
afforded some point of resistance beyond the bone ; and this it is really which 
has constituted one of the greatest impediments to reduction. It is not that the 
muscles are in such an extraordinary state of extension or rigidity that they 
must be operated against with great force ; it is not that the margin of the 
glenoid fossa is an elevated barrier, like the margin of the acetabulum, over 
which the bone must be lifted before it can fall into its socket ; but the explana- 
tion of the difficulty so often experienced in producing effective extension and 
counter-extension is to be sought for mainly in the fact that the scapula, upon 
which the humerus rests, is movable, being held to the body by little else than 
muscles, which, in fact, bind the scapula much less firmly to the body than the 
muscles of the shoulder now bind the scapula to the arm ; while at the same 
time the scapula itself presents very few points against which a counter-extend- 
ing force can be properly and efficiently applied. 

Occasionally it will be only necessary to elevate the arm to an acute 
angle, or to a right angle with the body, when, the resistance of the 
deltoid and supraspinatus being overcome, the bone will at once resume 
its place. In several instances which have come under my notice nothing 
more has been necessary; and where it can be done, the least possible 
pain and injury are inflicted. It is the method, therefore, which in all 
recent cases I have first tried and would wish to recommend. By it 
I have more than once succeeded when other and more violent efforts 
failed. At other times it will be necessary to add to this simple manipu- 
lation only a moderate degree of extension, such as the hands of the 
surgeon can make, without the application of direct counter-extension 
except what is effected by the weight and resistance of the body. 

Professor Moses Gunn, of the Rush Medical College, Chicago, who regards 
the upper and untorn portion of the capsule as the chief obstacle to the reduc- 
tion, says : '' For the reduction of this dislocation it is convenient to have the 
patient sit upon the floor. The arm is then raised to an angle of 45 degrees 
from the horizontal, and intrusted to an assistant, while the surgeon places his 
hands on the shoulder with the tips of the fingers in the axilla, resting on the 
dislocated head. The assistant now makes upward and outward traction, and 
the head glides into place followed by the surgeon's fingers in the axilla. The 
arm is then lowered to the pendent position, keeping up the tension till the arm 
is by the side of the body." 1 

The late Dr. John T. Darby, Professor of* Surgery in the University of the 
City of New York, informed me that he had been very successful in reducing 
dislocations of the shoulder, by adopting a rule similar to that which I have laid 
down for reducing dislocations of the thigh, namely, to carry the arm only in 
those directions in which it meets with the least resistance. He found that, in 
most cases, he could carry the arm up to nearly or quite a perpendicular, by 
humoring the action of the muscles ; and that in this position the reduction was 
easily effected. I have no doubt that the principle, as stated by Professor 
Darby, is sound, and that in nearly all dislocations the same may be applied 
successfully, whenever we can depend upon manipulation alone. 

If, however, the bone refuse to move, we shall then be obliged to con- 
sider upon what point and by what means we can best apply a counter- 
extending force. Ample experience has taught me that the extremity 
of the acromion process is the only available point when we are making 

1 Gunn, The Philosophy of Manipulation in the Eeduetion of Hip and Shoulder Disloca- 
tions. Read before the American Surgical Association, 1884. Also Chicago Med. and Surg. 
Journ. and Exam., May, 1884. 



DISLOCATIONS OF THE SHOULDER. 575 

the extension in a line below a right angle, or in a line downward more 
or less approaching the axis of the body. It has been supposed that the 
counter-extension could be made in the axilla against the inferior margin 
of the scapula ; but several obstacles are presented to the successful 
application of force at this point. The axillary space is narrow and deep, 
so that even with the ingenious contrivance of placing first a ball of 
yarn in the axilla, and upon this the heel of the operator, it will be 
found exceedingly difficult to enter the axilla without at the same time 
pressing with considerable force against its muscular margins ; but to 
press upon the pectoralis major and latissimus dorsi is to neutralize our 
own efforts. If, however, the heel or the ball does press fairly into the 
axilla, it will not find the scapula readily, but it must impinge first upon 
the head of the humerus, which is always a little to the inner side of the 
scapula. If it ever is made to reach actually the inferior border of the 
scapula, and I do not think it is, the effect must be still only to tilt the 
scapula upon itself by throwing back its lower angle, and not to separate 
the glenoid cavity or its upper and anterior margin from the head of the 
humerus. 

Whatever success, therefore, may have attended this mode of practice, 
either in my own hands or in the hands of other surgeons, must be 
ascribed not to the counter-extension thus effected, but simply to the 
operation of the heel as a wedge, which, by insinuating itself between 
the body and the head of the bone, has thrust it outward and upward 
into its socket; or to its having acted as a fulcrum upon which the 
humerus has operated as a lever. It is to the extremity of the acromion 
process, then, that we must apply our counter-extension when we are 
employing this mode of extension. The fingers or hands of a faithful 
assistant may answer the purpose, or, having removed his boot, the 
operator may often press successfully with the ball of his foot, and the 
more he carries the arm outward, the more secure will be his seat upon 
the process ; or we may adopt some of the contrivances for securing the 
process which have been suggested by other surgeons ; such as a band 
crossing the shoulder, and made fast to a counter-band, which passes 
through the armpit and against the side of the body. 

Dr. Physick, of Philadelphia, reduced a dislocation in this way as early as the 
year 1790, in the case of a patient admitted to St. George's Hospital, in London, 
while he was a student of medicine, and he subsequently taught the same in his 
lectures. Physick directed that an assistant should press firmly against the 
process with the palm of his hand. Dorsey and Hays approved of the same 
method, 1 and perhaps a majority of American surgeons have regarded it favor- 
ably. 

If we pull directly outward, at a right angle with the body, we may 
still continue to press upon the acromion process with the foot. 

Prof. N. R. Smith 2 says : " What surgeon of experience has not encountered 
the difficulty which almost always occurs in fixing the scapula?" and he then 

1 Physick, Amer. Journ. Med. Sci., vol. xix. p. 386, Feb. 1837. Dorsey's Elements of 
Surgery, vol. i. p. 214. Philadelphia, 1813. 

2 Smith's Med. and Surg. Memoirs, Baltimore, 1831, p. 337; also Amer. Journ. Med. 
Sci., July, 1861 ; also Amer. Med. Times, Nov. 9, 1861 ; paper by Stephen Kogers, M.D. 



576 



DISLOCATIONS OF THE SHOULDER. 



proceeds to give what seems to him the most effectual mode of rendering the 
scapula immovable, namely, to make the counter-extension from the opposite 
wrist. By this method the trapezii are provoked to contraction, and the scapula 
of the injured side is drawn firmly toward the spine and the opposite scapula. 
In illustration of the value of this procedure he relates the case of a gentleman 
who had suffered a dislocation of his left shoulder, and upon whom an unsuccess- 
ful attempt at reduction had already been made by a respectable surgeon. Dr. 
Smith, being called, proceeded as follows : Two gentleman made counter- exten- 
sion from the opposite wrist, while Dr. Smith made extension from the wrist of 

Fig. 360. 




N. R. Smith's method. 



the injured side, at first pulling it downward, but gradually raising it to the hori- 
zontal direction, and then gently depressing the wrist. On the effort being 
steadily continued for two or three minutes, the bone was observed tojslip easily 
into its place. ; 

But no position places the scapula so completely under our control as 
that in which the arm is carried almost directly upward, and the foot is 
placed upon the top of the scapula. By this method we may succeed 
generally when every other expedient has failed ; but it probably in- 
creases the danger of lacerating the axillary artery and vein ; and even 
when employed in recent cases, it must sometimes do serious injury to 
the muscles about the joint (Fig. 361). 

In Lister's case of rupture of the axillary artery, and in Agnew's case of 
rupture of the axillary vein, the accidents occurred when the arm was drawn 
upward. 



DISLOCATIONS OF THE SHOULDER 



577 



La Mothe was the first to recommend pulling directly upward ; l but 
as early as the year 1764, Charles White, of Manchester, made fast a set 
of pulleys in the ceiling, and placing a hand around the wrist of the dis- 



Fig. 361. 




Reduction by extension upward. 

located arm. he drew the patient up until the whole body was suspended. 
No pressure, however, was made upon the scapula from above, which is, 
no doubt, the most essential part of the process. 2 

Fig. 362. 




La Mothe's method, modified. 



1 La Mothe, Amer. Journ. Med. Sci , vol. xix. p. 387, Nov. 1836, from Melanges de Med. 
etChir., Paris, 1812. 

2 C White, Amer. Journ. Med. Sci., Nov. 1836, from Med. Obs. and Inquiries, vol. ii. p. 
273, London, 1764. 



578 



DISLOCATIONS OF THE SHOULDER. 



Fig. 363. 



By La Mothe's plan, Jobert succeeded after twenty-three days, when all the 
usual methods had failed. 1 Sometimes this procedure is modified by placing the 
hand of the operator against the top of the scapula, as is shown in the accom- 
panying drawing (Fig. 363) ; and I have several times succeeded in this way 
after other measures have failed. 

A gentle movement backward or forward, a slight rotation of the limb, 
or suddenly dropping the arm toward the body, diverting the attention 
of the patient, are little tricks of the operator, which now and then prove 
successful. 

[Bryant approves the method of White, of Manchester, revived by Mr. Lowe 
(Fig. 363). The patient sits upon the floor, and the surgeon, standing behind 
him on a sofa, forcibly extends the dislocated arm up- 
ward, the scapula being fixed by the surgeon's foot.] 

Sir Astley Cooper thus describes his method of applying 
the heel to the axilla (Fig. 364) : " The patient should 
be placed in the recumbent posture upon a table or sofa, 
near to the edge of which he is to be brought ; the sur- 
geon then binds a wetted roller around the arm imme- 
diately above the elbow, upon which he ties a handker- 
chief; then he separates the patient's elbow from his 
side, and, with one foot resting upon the floor, he places 
the heel of his other foot in the axilla, receiving the 
head of the os humeri upon it, while he is himself in the 
sitting posture by the patient's side. He then draws 
the arm by means of the handkerchief, steadily, for three 
or four minutes, when, under common circumstances, the 
head of the bone is easily replaced ; but if more force 
be required, the handkerchief may be changed for a long 
towel, by which several persons may pull, the surgeon's 
heel still remaining in the axilla. I generally bend the 
forearm nearly at right angles with the os humeri, because 
it relaxes the biceps, and consequently diminishes its 
resistance." 
Sir Astley was also accustomed in some cases to reduce 
the dislocation by substituting the knee for the heel. Placing the patient upon 
a low chair, the axilla is laid over the knee of the operator, and while one hand 




Reduction by exten- 
sion of the arm upward. 
(Bryant.) 



Fig. 364. 




Sir Astley Cooper's method of applying extension with the heel in the axilla. 
1 Ibid., vol. xxiii. p. 237, Nov. 1838. 



DISLOCATIONS OF THE SHOULDER. 



579 



Fig 



steadies the acromion process and scapula, the other presses downward upon the 
lower end of the humerus (Fig. 365.) 

If some hours or days have elapsed since the occurrence of dislocation, 
it will be necessary to resort to chloroform or ether for the purpose of 

paralyzing the muscles, as well as with 
the view of preventing pain ; and it 
may be necessary, in addition, to resort 
to pulleys, or to some similar perma- 
nent mode of extension. The same 
measures also sometimes become neces- 
sary in very recent cases, especially in 
muscular subjects. 

In employing the pulleys we gener- 
ally operate, not exactly in a line with 
the axis of the body, nor at more than 
a right angle, but between an angle of 
45° and a right angle. 

Mr. Skey has suggested a plan by which 
we may combine the principle of the heel 
in the axilla with the pulleys, but which 
plan would, in my judgment, be very much 
improved by a counter-extending force ap- 
plied to the acromion process. I ought to 
say, however, that Mr. Skey prefers that 
the scapula should not be fixed, believing 
that the reduction is much more easily 
efFcted when the glenoid cavity is drawn 
downward in the act of making the exten- 
sion. With all respect for the opinion of this distinguished surgeon, I cannot 
precisely agree with him ; and while I would be disposed to recommend in some 
cases a trial of his method of applying the pulleys, I would, at the same time, or 
certainly in the event of its failure, add the acromial support, and especially 

Fig. 366. 




Sir Astley Cooper's mode of operating 
with the knee in the axilla. 




Iron knob employed by Skey, instead of the beel. 

would I advise that the arm should be more abducted. The following is Mr. 
Skey's method, as described by himself: "There is no reason why, in very 
muscular subjects, or in old dislocations, the same principle may not be applied 
conjointly with the use of pulleys. For the purpose of retaining this admirable 
because most efficient principle, I employ a well-padded iron knob, which may 
represent the heel, from which there extend laterally two strong straight branches 
of the same metal, each ending in a bulb or ring of about four inches in length, 
the office of which is designed to keep the margins of the axilla as free from 
pressure as possible." The iron knob is to be pressed well up into the axilla 
and attached to cords fastened to a staple ; the patient lying upon his back or 
inclined a little to the opposite side. The arm is then to be drawn downward 
by the pulleys, " as nearly as possible parallel to, and in contact with, the body." 1 
In this way Mr. Skey says that he has succeeded in reducing a great many 
dislocations, even when occurring in very muscular men, and after some days', 



Skey, Operative Surgery, Amer. ed v p. 93. 



580 



DISLOCATIONS OF THE SHOULDER. 



weeks', or even months' duration ; and he thinks the plan especially applicable 
to cases which require long and persistent extension. 

Fig. 367. 




Skey's method of making extension and counter-extension with pulleys. 

Mr. Skey and many other surgeons prefer to make the extension from the 
hand. I have succeeded as well, and it seemed to be less painful to my patients, 
when I have followed the practice of Sir Astley, and made the extension from 
the arm. Sir Astley always made the extension more or less out from the line 
of the body, and generally almost at a right angle when using the pulleys ; the 
scapula being made fast by " a girt buckled on the top of the acromion," or by 
a split cloth (Fig. 368). 

Fig. 368. 




Sir Astley Cooper's mode of making extension with pulleys. 

Kocher l flexes the forearm upon the arm ; carries the elbow against 
the side of the body ; abducts the hand, in order to rotate the head of 
the humerus outward, until resistance is experienced ; carries the elbow 
forward, upward, and slightly inward, while the arm is still flexed at a 
right angle, and the hand maintained in a position of forced abduction ; 



1 Kocher, Rev. Men. de Chir., 1882, t. 2, p. 834. 



DISLOCATIONS OF THE SHOULDER 



581 



then the arm is rotated inward, and the hand is carried upon the sound 
shoulder. All of these manoeuvres are to be executed as slowly and 
gently as possible. 



Fig. 369. 




Kocher's method ; first movement, outward rotation. 

[Kocher's method has proved very succeessful. It is based on the following 
facts : In this dislocation the posterior portion of the capsule is untorn. The 
same is true of the tendons of the scapular muscles which cover it posteriorly ; 
the lower portion of the capsule, forming the rent, is tense, but the tension 
is greatest at the upper part of the capsule, between the long tendon of the 
biceps and the upper margin of the subscapular muscle, where it is strength- 



Fig. 370. 



Fig. 371. 




Kocher's method ; second movement, elevation 
of elbow. 



Kocher's method; third movement, in- 
ward rotation and lowering of elbow. 



ened by the coraco-humeral ligament. This part of the capsule is twisted like 
a firm cord, and stretched. If the humerus is rotated outward, so that the 
forearm is turned out, this cord will also be rotated outward, the posterior 
part of the capsule will be removed from the fossa, and the torn capsule will 



582 DISLOCATIONS OF THE SHOULDER. 

gape. The head of the bone remains fixed against the edge of the glenoid 
fossa, as the upper and lower parts of the capsule are still tense. But when the 
elbow is carried forward and raised, while the arm is held rotated outward, the 
upper part of the capsule relaxes and the head enters its socket, for the tension 
of the lower part of the capsule keeps it from moving forward ; rotation inward 
completes the reduction. In rotating the head outward by abducting the hand 
there should be greater fulness apparent in the outer deltoid region ; if the resist- 
ance begins before the fulness appears, maintain the external rotation of the arm 
and flexion of the elbow, and move the elbow forward and inward until the arm 
is horizontal. As the outer deltoid region now becomes more marked, rotate the 
arm inward, and carry the hand to the opposite shoulder.] 

The practice of Prof. Smith, of Philadelphia (Figs. 372, 373), according to whom 
nearly all dislocations of the shoulder, of a recent date, may be promptly and 
easily reduced by manipulation alone, consists, first, in flexing the forearm upon 
the arm, while, at the same moment, the elbow is lifted from the body ; second, 
in rotating the humerus upward and outward, employing the forearm as a lever ; 
and third, in reversing this last movement — that is, rotating the humerus down- 
ward and inward — while at the same moment the elbow is carried again to the 
side. 1 When the dislocation is into the axilla, this latter manoeuvre will gener- 
ally succeed ; but if the head of the humerus has slipped forward, even only 

Fig. 372. Fig. 373. 





Extension, adduction, and rotation outward. (Smith.) 

sufficient to engage itself slightly under the tendons of the coraco-brachialis and 
biceps (approaching to, or actually in the condition of a subcoracoid dislocation), 
the outward rotation of the humerus will inevitably thrust the head further for- 
ward, and fasten it more certainly underneath these tendons ; while the rotation 
of the humerus in the opposite direction will alone often be sufficient to carry 
the head directly into the socket. 

[Dr. Kelly, 2 an Irish surgeon, resorts to the following method : The patient 
lies upon the edge of a bed about three feet high ; the surgeon stands by the 
side of the bed facing toward the head, his hip against the patient's chest near 
the axilla ; he then draws the arm and forearm of the affected side across the 
front of his own pelvis and around to the opposite hip ; now, holding the wrist of 
this arm firmly with one hand against himself and making pressure on the head 
of the humerus with the thumb of the other hand, he slowly rotates his body 
outward and draws the head to the socket.] 

Ancient Dislocations of the Shoulder. — The procedure and the prin- 
ciples involved in the reduction of old dislocations, or of dislocations 
requiring the interposition of mechanical appliances needs a more com- 
plete exposition. If the dislocation is recent, and reduction is found 
impossible without the aid of mechanical apparatus, the difficulty will be 
understood to consist mainly, if not altogether, in the resistance offered 
by the muscles. If, in a few exceptional cases, a '»' buttonholing " of the 

i H. H. Smith, Gross's Surg., ed. of 1863, p. 152. 
2 Dublin Journ. Med. Sei., Sept. 1882. 



DISLOCATIONS OF THE SHOULDER. 583 

head and neck by the capsule, or the margin of the glenoid fossa, presents 
itself as an obstacle, it must be considered an unusual and extraordinary 
impediment, the existence of which may be regarded rather as possible 
than probable. Almost our sole purpose, then, it will be understood, 
in all recent cases requiring mechanical appliances, and in some ancient 
cases, is to overcome the contraction of the muscles. 

I prefer always to place the patient upon a mattress laid upon the floor; two 
silk handkerchiefs, or two pieces of a cotton roller, are then laid along the radial 
and ulnar sides of the humerus, and over the middle of these, immediately above 
the condyles, a wetted roller is applied, its end being made fast with a needle 
and thread rather than with a pin. The upper ends of the longitudinal strips, 
or of the handkerchiefs, are now turned down and tied to the opposite ends, 
thus converting them both into lateral loops. For the purpose of making coun- 
ter-extension, a sheet is passed around the body under the axilla, and made fast 
to a staple ; while an intelligent assistant is to manage the scapula with his 
naked hands, either by pulling with his fingers placed under the process, or by 
pushing with the palm of his hand and ball of his thumb. The pulleys, secured 
to a staple exactly opposite to that which holds the counter-extending band, are 
made ready, but not for the present attached to the arm. 

As soon as the patient is placed completely under the influence of an 
anaesthetic, the operator is ready to proceed with the reduction. It is 
my maxim never to attempt to accomplish by complicated and violent 
measures what may be done as well by more simple and gentle means. 
I think it proper, therefore, to make several attempts at reduction by 
manipulation alone, aided now by the anaesthetic, the extending and 
counter-extending bands, etc., before resorting to the pulleys. Seating 
himself upon the mattress, his boots being removed, the surgeon should 
bend the forearm to a right angle with the arm, and planting one heel 
in the axilla, with one hand he should seize upon the loops at the elbow, 
and with the other steady the hand and forearm of the patient, while he 
proceeds to make firm traction for a few seconds in the line of the body, 
or only a little out from this line. Failing in this, he may direct the 
assistant to seize upon the scapula, and make counter-extension ; still 
not succeeding, he may change his foot from the axilla to the acromion 
process, and pull directly outward at a right angle with the body, or he 
may swing himself gradually around until he comes to be above the head 
of the patient, and the foot presses firmly upon the top of the scapula ; 
now descending again in the same direction, he will very probably find 
the limb reduced, or capable of being reduced easily, by operating upon 
it as a lever by laying it across the body while at the same moment it is 
rotated slightly inward. 

If still the reduction is not accomplished, the pulleys must at once be 
put in requisition. The sheet, passed around the chest and fastened to 
a staple, is only a means of supporting the body and rendering it more 
steady ; as a means of counter-extension its value is inconsiderable. To 
make fast the scapula, we must still rely mainly upon the naked hands 
of strong men, or upon a strap drawn firmly across the process and held 
in place by an assistant. 

Whenever we employ extension without the aid of anaesthetics, as sometimes 
we are compelled to do, it must be constantly borne in mind that it is proposed 



584 • DISLOCATIONS OF THE SHOULDER. 

to conquer the muscles by fatiguing them, and that this cannot be done by a 
force suddenly applied, however great it may be, but only by gentle, steady, and 
long-continued extension. The muscles, when attacked openly and vigorously, 
resist, and will suffer laceration rather than yield, while, on the other hand, an 
insidious but persevering approach seldom fails to end in their defeat. The 
same is true, but in a much less degree, when the patient is insensible from 
anaesthesia. 

The forearm is again flexed, and the arm carried out to a right angle 
with the body, the pulleys secured to the loops, and the assistant takes 
hold upon the process, while the surgeon draws gently upon the rope 
attached to the pulleys ; as soon as everything is moderately tense, he 
is to desist for a few moments. Again the rope is drawn upon gently, 
and again the progress of the extension is suspended. In this way the 
operator is to proceed during half an hour, or two hours, as the nature 
of the case may demand; occasionally rotating the humerus, and occa- 
sionally lifting its head toward the socket. Meanwhile, it is understood 
that the principal counter-extension is made by the assistants, who must 
relieve each other, at the acromion process. The sheet in the axilla, or 
rather against the side of the chest, has some value in this respect when 
the arm is at a right angle with the body, but in itself it cannot control 
the scapula, only as it holds the body to which the scapula is attached. 
Much, therefore, as we may regret the inconvenience of making counter- 
extension by hands alone, experience and anatomy alike must teach that 
here it is the only mode. If these dislocations are reduced often by 
other methods, as no doubt they are, then it is only an evidence that in 
these examples little or no counter-extension was necessary. Sometimes 
the dislocation is not reduced when the extension is given up, but if then 
a resort is promptly made to some one of the simple methods already 
described, while the muscles are still exhausted, it very often happens 
that the reduction is easily accomplished. It will be prudent in all 
cases, in order to prevent a redislocation, whether the dislocation is recent 
or ancient, as soon as its reduction is effected, to place the arm in a sling 
and secure the elbow to the side by a few turns of a roller. I do not 
think the axillary pad necessary, and I am afraid that it has sometimes 
done as much mischief as the dislocation itself. 

The following example will illustrate the variety of expedients to which we 
are obliged sometimes to resort before our efforts prove successful : 

T. L., of Niagara Co., N. Y., aet. 52, a laborer, and a muscular man, dislo- 
cated his right arm into the axilla, by jumping from the cars when they were in 
full motion. The blow was received upon the shoulder. An intelligent country 
surgeon, assisted by several other persons, attempted reduction within an hour 
after the accident, but failed, and as the patient had some distance to travel, he 
was not brought under my notice until eighteen hours had elapsed. We first 
administered chloroform, and then, while an assistant held firmly upon the 
acromion process, I pulled in the line of the body, then outward, and finally 
upward, but to no purpose. Having then applied Jarvis's " adjuster," and after 
the arm had been kept extended at a right angle with the body fifteen minutes, 
we removed the apparatus, and found the bone in its place. 

J. H., set. 50, a very large and powerful man, fell while intoxicated, and dis- 
located his left humerus into the axilla. No surgeon was called until the tenth 
day, when he first consulted Dr. Dudley, who at once brought him to me. With- 
out delay we applied the pulleys, and placing the arm at a right angle with the 
body, we made extension fifteen minutes ; occasionally also rotating the arm. 



DISLOCATIONS OF THE SHOULDER. 585 

We then removed the pulleys, and while an assistant held upon the acromion 
process, with my heel in the axilla, I made extension in the line of the axis of 
the body, then outward, and finally upward with my foot upon the top of the 
scapula. I next seated my patient in a chair, and drew his arm and axilla 
forcibly over my knee. The bone was not yet reduced ; I therefore bled him 
twenty-four ounces, or until partial syncope was induced, and proceeded to 
repeat most of these processes, but with- no better result. At this moment I 
determined to use sulphuric ether, which had just been introduced as an anaes- 
thetic, and while he was completely under its influence the pulleys were again 
applied, and the extension continued for some time, and until the rope broke. 
He was then again placed in a chair, and the axilla brought over my knee, when 
in a moment the reduction was accomplished. 

J. McK., aet. 89, was admitted to ward 28, Bellevue, in Nov. 1866, with a dis- 
location of the humerus into the axilla, which had existed seven weeks and one 
day. The deltoid was much wasted and the hand somewhat numb. Before the 
class of medical students, the patient being under the influence of ether, the 
reduction was effected ; but not until various methods of manipulation and ex- 
tension had been tried and had failed. Having finally carried the arm directly 
upward— La Mothe's method — and in this position employed extension, the arm 
was again brought down, and with moderate manipulation the reduction was 
effected. The return of the bone was sudden, and was accompanied with a 
slight grating sensation ; it was observed also, that a hard bony projection was 
left in the axilla, which was no doubt the margin of a new socket. The head 
of the humerus could be plainly seen and felt in its socket, rendering it certain 
that I had not broken the surgical neck of the humerus. 

J. B., of Buffalo, aged 45 years, an Irish laborer, tolerably muscular, but 
spare, fell down a flight of stairs, and dislocated his left humerus into the axilla. 
The shoulder became much swollen, and was very painful, but he did not sus- 
pect a dislocation and did not consult a surgeon. Eight weeks after the acci- 
dent he applied to me. There were present the usual signs of this dislocation, 
but the arm was by careful measurement one inch and half longer than the 
other. The reduction was accomplished on the same day. The time occupied in 
the reduction was about two hours. An attempt was first made w T ith the heel in 
the axilla and with violent rotation and extension. The same plan was repeated 
with the aid of ether, which was administered freely. Jarvis's adjuster was now 
applied, with no result, except that, either in consequence of the force employed 
by the adjuster, or in consequence of the free use of ether, or of both, he be- 
came convulsed violently, which was accompanied by frothing at the mouth and 
other grave symptoms. The adjuster was removed, and the exhibition of ether 
discontinued. As soon as the convulsions ceased, and before consciousness had 
returned, extension, rotation, etc., were again made by hands. Finally, after all 
extension was relinquished, placing my knee in the axilla, I reduced the bone 
by a very slight rotary action upon the arm ; the bone was at once plainly in its 
socket, but the unusual length of the limb continued, being one inch and a half 
longer, though it could be shortened to the same length as the other by lifting 
the elbow. A pad was placed in the axilla and the arm secured with a sling 
and roller. The next day the arm remained in place, but it was now only one 
inch longer than the other. At the end of a fortnight it was only three-quarters 
of an inch longer, and could be reduced to the same length by lifting ; the pain 
and swelling about the shoulder, which never were great, were subsiding, and 
the patient was dismissed. 

However skilfully our efforts may be directed, they will be found 
occasionally to fail ; either owing to adhesions which have taken place 
between the head of the bone, or rather its capsule, and the adjacent 
tendons, muscles, etc., to some extraordinary position of the head and 
neck of the bone in its relation to ligamentous or tendinous structures, 
to a filling up of the glenoid fossa, or to some other cause not fully ex- 
plained. Such failures have happened not only in the hands of ignorant 
and unskilful surgeons, destitute of appliances, but also in the hands of 



586 DISLOCATIONS OF THE SHOULDER. 

those who are the most expert, and who are the most completely pro- 
vided with all the necessary apparatus. Indeed, if the truth were known, 
it would probably be found that the number of failures after the sixth or 
eighth week has been greater than the successes. The records of sur- 
gery, however, furnish a great many examples of ancient dislocations of 
the humerus reduced after periods ranging from one month to six, or 
even longer. 

Sedillot 1 claims to have succeeded after one year and fifteen days, and Koenig 2 
after eight years. 

In 1819, Weinhold, for the purpose of reducing an ancient dislocation of the 
humerus, cut the pectoralis major three fingers' breadth from its insertion, and 
obtained an easy reduction. Wutzer, 3 in two cases, cut the coraco-brachialis. 
Poinsot, to whom I am indebted for this statement, adds that the result is not 
known to him. Dieffenbach was able to accomplish the reduction of a forward 
dislocation after two years, but not until he had cut the tendons of the pectoralis 
major, latissimus dorsi, teres major, and teres minor, and had divided the liga- 
ments surrounding the new joint. 4 Simon, 5 in 1852, and Polaillon, 6 in 1881, 
combined subcutaneous incisions of the fibrous tissues surrounding the joint, with 
prolonged extension, and were thus enabled to reduce this dislocation. Poinsot, 
however, does not think these incisions were of any particular value. In a 
woman, set. 48, who had a forward and downward dislocation of seven months' 
standing, accompanied with great pain and inability to use the limb, H. Burck- 
hardt 7 through an open incision divided the adhesions, and during the efforts at 
reduction the great tuberosity was partially torn off. The result was a very 
sensible improvement in the condition of the arm. Mears, 8 of Philadelphia, 
has twice practised subcutaneous osteotomy, in order to establish a false joint, 
and with results satisfactory to himself. Despres 9 has had recourse, in two cases, 
to fracture of the neck of the humerus, without intending to establish a pseudo- 
arthrosis. Poinsot, in commenting upon these cases, says that the results of the 
two cases, as reported, are not likely to impress the reader favorably. In a case 
in which the head of the humerus, long dislocated, pressed upon the brachial 
plexus, causing great suffering, Dr. Edward Warren, of Baltimore, practised 
resection, in 1869, giving immediate and permanent relief. 10 

Dr. Thomas Annandale, Surgeon to the Edinburgh Infirmary, in the case of 
a woman 62 years old, with a subclavicular dislocation of six weeks' standing, 
having failed to reduce the bone, and the patient suffering great pain on account 
of the pressure upon the axillary nerves, cut down upon the head of the hume- 
rus, along the inner border of the deltoid, and after separating the axillary artery, 
which was adherent to the bone, and having sawn through the surgical neck of 
the humerus, he removed the head in fragments and with great difficulty, inas- 
much as it was firmly bound to the ribs by fibrous and bony tissues. In the 
course of this procedure he wounded the circumflex artery so near to its origin 
that he was obliged to tie the subclavian above and below the origin of the cir- 
cumflex. The operation was performed February 16, 1875. On the 18th the 
hand and forearm became gangrenous, and on the 19th she died. 11 

Volkmann 12 practised resection in a man, set. 53, who had a subcoracoid dislo- 
cation of five weeks' standing, and which it was found impossible to reduce. 

1 Sedillot, Art. Lux., Die. Encyc. des Sci. Med., 2d ser. t. iii. p. 281. 

2 Koneig, by Ceppi, Rev. Men. de Chir., 188, t. ii. p. 828. 

3 Wutzer, Kronlein, die Lehre von Lux. in Deuts. Chir. von Billroth u. Lueke, Lieferung. 
26, p. 71. 

4 Dieffenbach, Boston Med. and Surg. Journ., vol. xxii. p. 382, from Mediein. Zeitung. 

5 Simon, from Kronlein, loc. cit. 6 Polaillon, Poinsot, op. cit., p. 834. 

7 Burckhardt, Wiirtemberg Med. Correspond., 1878, No. 4, p. 35. 

8 Mears, Phila. Med. and Surg. Reporter, Oct. 1877. 

9 Despres, Bull. Soc. de Chir. de Paris, 1879, pp. 24 et 742. 

10 Warren, Gross's Lecture, Amer. Journ. Med. Sci., April, 1876, p. 452 ; also Baltimore 
Med. Journ., Sept. 1871, p. 532. 

11 Annandale, Med. Times and Gaz., May 29. 1875, p. 576. 

12 Volkmann, Popke, Inaug. diss. Halle, 1882 ; Anal, in Centralblatt fiir Chir., 1883, p. 28. 



DISLOCATIONS OF THE SHOULDER. 587 

The incisions were made through the axillary space, and at once opened into a 
cavity of the size of the fist, inclosing the head of the bone, and containing 
blood and serum. It was ascertained now that the blood, which still continued 
to flow, came from the axillary vein, which had been wounded by a sharp frag- 
ment of bone, separated from the lesser tuberosity. The vein was ligated, and 
the resection made, but notwithstanding the resection the head of the humerus 
could be only partially replaced. At the end of three weeks this patient left the 
hospital, with some improvement in the position and motion of the arm. In the 
case of a man, set. 30, with a dislocation of seven or eight months' standing, and 
in which redislocation was constantly occurring, Cramer 1 practised resection 
with most satisfactory results. In a case of repeated redislocations of the hume- 
rus Kuster 2 also practised resection, and obtained at the end of seven weeks 
"very satisfactory results." Volkmann 3 has also practised resection in the case 
of a man, set. 30, who had repeated spontaneous redislocations. The incisions 
were made from the anterior surface of the arm. Subsequently the patient 
informed Volkmann, by letter, that he could use his arm a great deal better 
than before the operation. 

[Open arthrotomy has been practised with a gratifying measure of success, 
and with antiseptic precautions gives promise of being an accepted method. 
Albert operated for a subcoracoid dislocation, making an incision in front ; 
while making rotatory movements to return the head to the socket, a fracture 
occurred at the surgical neck ; the head was drawn into place by two hooks, and 
the fragments were united by suture; a false joint resulted, which, however, 
gave a more useful limb. Thiersch failed to effect a reduction. Burkhardt 
operated on .a woman seven months after luxation; the incision was midway 
between the coracoid and acromion ; after dissecting away the strong fibrous 
bands which were attached to the head, reduction was effected, though the 
greater tuberosity was torn off. Recovery followed, and three months after the 
limb could be abducted 45° and the hand carried to the opposite shoulder. 

Dr. Heron Watson operated four weeks after the accident on a subcoracoid 
dislocation. An incision was made about eight inches long over the interval 
between the deltoid and the clavicular portion of the pectoralis major ; the cap- 
sule was found torn completely away ; the finger first felt the glenoid cavity, 
then a rough surface on the head of the humerus which proved to be the place 
from which the two upper facets of the greater tuberosity had been broken off. 
The head of the humerus lay under the coracoid process. All efforts to replace 
the bone failing, a narrow lithotomy-scoop was passed to the inner side and 
underneath the head, which was thus lifted into the glenoid cavity. A drainage- 
tube was inserted and the wound closed, which mostly united in a week. The 
patient developed insanity, but recovered, and at the end of eight months could 
abduct his arm 70° and place his hand on the top of the head ; external rotation 
and supination are impaired. Garmany, of New York, operated on a recent 
case successfully. 

Mr. Lister has recently performed this operation twice on the same person 
with most satisfactory results. The patient was a man, set. 47, who fell a dis- 
tance of forty feet on his outstretched arms, producing subcoracoid luxation of 
both shoulders. Eight weeks after the accident he entered King's College 
Hospital in a very helpless state, unable to dress himself, with the arms almost 
fixed in a slightly abducted position, and rotation very limited, particularly on 
the right side. The first operation was on the left side, as follows : An incision 
was made from the coracoid process downward and somewhat outward in the 
interval between the delioid and pectoralis major; the tendon of the subscapu- 
laris was divided, and with a periosteum-detacher the soft parts were separated 
from the head of the bone and the inner part of the neck so completely as to 
leave no doubt that the vessels were entirely detached from the bone ; pulleys 
were then applied, and as they put fibrous bands on the stretch these were 
divided; the head of the bone still refusing to return to its position, the bone 
was more completely cleared and the pulleys again applied ; this failing, the 
head of the bone was protruded as for resection, the external rotators cut 

1 Cramer, Berliner klin. Wochenschrift, 1882, ~No. 2. 

2 Kuster, Rev. Mens. Chir., 1882, p. 867. 3 Volkmann, Popke, loc. cit. 



588 DISLOCATIONS OF THE SHOULDER. 

through at their insertions ; the pulleys were again employed and suddenly 
relaxed by pulling a slip-knot, and at the same moment rotation outward and 
adduction of the limb were performed ; the head was thus brought nearer to the 
glenoid cavity; it went still nearer on a second attempt of the same description, 
and at a third the head of the bone slipped into its normal place. The wound 
did well, and the following week he operated on the other shoulder in a similar 
manner, except that he at once protruded the head of the bone, dividing all of 
the attachments of the rotators ; at the second attempt the pulleys drew the bone 
into its proper position. The wound also did well. There was no suppuration 
in either wound, but the passive motion which was maintained seemed to keep 
up a serous oozing, and it was nearly two months before the last wound was per- 
fectly cicatrized. Fifty-one days after the first operation the patient put on his 
coat unaided. About four and a half months after the operation the patient 
exhibited all the natural movements of the arm in their normal degree except 
elevation of the limb, and he stated that he could do any hard farm work as 
well as ever. 

A second case of double dislocation of the head of the humerus came under 
the care of Mr. Lister, caused by epileptic seizures. He performed the same 
operation on the left shoulder, but not with as satisfactory results as regards the 
usefulness of the limb as in the preceding case. The operation on the right 
humerus, six months later, consisted in exposing the head and chiselling away 
its articular portion, but without interfering with its tuberosities ; this allowed 
the bone to drop back into the glenoid cavity. Recovery was prompt, and the 
patient gained usefulness of this arm much more rapidly than of the other. The 
final result proved to be good on both sides, for it is stated that he had nearly 
gained the full use of his arms two years after the first operation, the defect 
being inability to raise the arms above the horizontal. 1 ] 

Accidents Occurring during Attempts at Reduction of Dislocation. 

Rupture of the Axillary and other Arteries. — Blackman, of Cincin- 
nati, having met with one of these unfortunate accidents in his own 
practice, had the candor to make a public statement of the case and of the 
circumstances which attended it. In a letter to the editor of the 
Western Lancet, published in the November number for 1856, he wrote 
as follows : 

"About the 10th ult., aided by yourself, I succeeded in reducing by manipula- 
tion, without the pulleys, a dislocation into the axilla, of eighty days' standing. 
The reduction was accomplished in a very few minutes, under the influence of 
chloroform and ether, and the next morning the patient left for the country, in 
a comfortable condition. Since that I have received no tidings from him. 
Encouraged by the result in this case, another patient, himself a physician, a 
tall, athletic man, and about fifty years of age, decided to submit to the same 
manipulation, although his arm had been dislocated for about sixteen weeks. 
The dislocation was downward and inward, and about the tenth week an unsuc- 
cessful attempt, by another surgeon, had been made with the pulleys, to which 
the force of six men was applied for two and a half hours. The patient being 
under the influence of chloroform and ether, I commenced my manipulations, 
adducting, rotating, abducting, and elevating the arm. These efforts had been 
made for about ten minutes, and the least possible violence employed, when a 
tumefaction appeared in the pectoral region, which, in a few minutes, attained 
a considerable size. Supposing that the axillary artery was ruptured, as no 
pulse could be felt at the wrist, a ligature was immediately applied to the vessel 
at the upper part of its course. The operation was performed about 10 o'clock 
A. m., and compression of the pectoral region made by means of a sponge and 
broad roller. On removing this the next morning, the tumefaction had nearly 
disappeared. The patient continued comfortable, and about nine days after the 

1 London Lancet, Jan. 1, 1890. 



ACCIDENTS DURING REDUCTION. 589 

application of the ligature I was compelled to leave the city on a professional 
visit to Indiana. I left on Friday afternoon and returned on Monday morning, 
at which time I learned that my patient had died on Sunday morning, from 
hemorrhage at the seat of ligature." 

M. Panas 1 saw at the Hospital St. Louis a diffuse aneurism in the armpit 
supervening fifteen days after a reduction of a dislocation (intracoracoidean) 
which was of forty-eight hours' standing. The reduction had been by ordinary 
manual extension, while the head was pressed forcibly outward by the thumbs 
sunk deeply into the axilla. M. Panas tied the subclavian artery in the neck, 
outside of the scaleni muscles. The patient succumbed three months later from 
articular suppuration. 

Gunther 2 reduced a recent dislocation under anaesthetics, by elevation and 
direct pressure upon the head of the humerus, in a man 20 years of age, who 
had before dislocated the same arm. At the end of three weeks an aneurism 
was discovered in the axilla. The subclavian was tied, suppuration ensued, 
the abscess opened, and death resulted from hemorrhage. W. Korte 3 reports a case 
in which a recent dislocation forward and inward was reduced by a bone-setter, an 
axillary tumor formed, which was punctured several times, and the patient died 
five weeks after the accident, of septicaemia. He reports also another case of a 
similar but ancient dislocation, in which several attempts were made at reduction, 
during one of which the axillary artery was ruptured. The aneurism soon 
opened spontaneously, and the patient died - of hemorrhage. In the case of a 
man, set. 62, admitted to the General Infirmary of Sheffield, England, with a dis- 
location of eight weeks' standing, slight attempts at reduction, with the heel in the 
axilla, resulted in the formation of an axillary tumor. The next day the axillary 
artery was tied, and new attempts at reduction were made. The patient died 
at the end of twenty- four hours. 4 M. Letievant, 5 of Lyons, found in his wards a 
patient with a dislocation of twenty days' standing. The reduction was effected 
under chloroform, but not until violent tractions had been made. It was fol- 
lowed immediately by an axillary aneurism and paralysis of the radial nerve. 
M. Letievant, after having tried successively digital and elastic compression, 
resorted to ligature of the axillary artery, outside of the scalenii. The aneurism 
got well, and the paralysis eventually disappeared. In Carruther's 6 patient, a 
dislocation having been promptly reduced, was soon reproduced. The second 
reduction was again easily effected, but on the following day there existed tume- 
faction and signs of incipient gangrene. Carruther amputated the arm and the 
patient died the next morning. The autopsy revealed a laceration of the axil- 
lary artery below the origin of the subscapular. A man 55 years of age, and 
having a dislocation of forty- eight days' standing, was subjected to repeated 
attempts at reduction, which resulted in a diffuse aneurism. Four months later 
he was admitted to Charing-Cross Hospital. Dr. Bellamy amputated the arm 
at the shoulder-joint, and the patient died during the operation. 7 Desault twice 
observed, after attempts to reduce old dislocations of the shoulder, " tumeurs 
aeriennes." It is quite probable, however, that in each case the tumor was caused 
by the rupture of a bloodvessel, and probably an artery. 8 Pelletan, also, at- 
tempting to reduce a dislocation of four months' standing, thought he produced 
a tumeur aerienne, but it being opened the patient bled to death. 9 Probably the 
axillary artery was torn. Malgaigne, attempting to reduce a dislocation of 
sixty-eight days' standing, was surprised by a sudden tumefaction in the axilla, 
and on the shoulder, which caused so much alarm as to induce him to discon- 
tinue his efforts. Ice was applied, and the hemorrhage, which he thought came 
from muscular branches, was arrested. 10 Verduc saw the axillary artery rup- 
tured in the same manner, in consequence of which the patient died. 11 J. L. 

1 Panas, Art. Epaule, Nouv. Die. Med. et Chir. Prat., t. xiii. p. 441. 

2 Gunther, quoted by Marchand, These d'Agreg., Paris, 1875, p. 40. 

3 Korte, Arch, fur klin. Chir., Bd. 27, Hft. 3, p. 631. 

4 British Med. Journ., Feb. 2, 1883. 

5 Letievant, Lyon Med., 14 Juil., 1878, p. 383. 

6 Carruther, Brit. Med. Journ., May 18, 1872. 

7 Bellamy, The Lancet. 1880, vol. ii. p. 260. (Poinsot, op. cit., pp. 838, 839.) 

8 Desault, Journ. de Chir.. t. iv. p. 301. 9 Pelletan, Chir. Clin., t. ii. p. 951. 
10 Malgaigne, Paris ed., 1855, p. 150. 

" Verduc, Operat. de la Chir., 1693, t. i. p. 559. 



590 DISLOCATIONS OF THE SHOULDER. 

Petit, DupuytreD, and Nelaton met with similar cases. C. Bell reports an 
example of rupture of the artery with extensive laceration of the muscles, which 
demanded immediate amputation. Delpech ruptured the artery, and his patient 
died immediately. 1 Flaubert was more fortunate, the effused blood being ab- 
sorbed after a few days, 2 John C. Warren, of Boston, tied the subclavian artery 
to arrest the progress of an enormous aneurismal tumor in the axilla, caused by 
the reduction of a recent dislocation. 3 Gibson, of Philadelphia, lost two patients 
from rupture of the artery in attempting to reduce old dislocations of the 
humerus, 4 and he relates another fatal case occurring in the practice of David, 
of Rouen. Leudet, of Rouen, lost a patient in this way in 1825. In this latter 
case, and in both cases occurring in the practice of Gibson, there was a fracture, 
also, of the lower margin of the glenoid cavity. Callender ruptured the artery 
in an attempt to reduce a dislocation at six weeks. 5 Mr. Lister met with the 
same accident. 6 

Poinsot suggests that in some of these accidents the dislocation itself, rather 
than the attempts at reduction, might have been responsible for the rupture of 
the axillary artery ; and in support of this suggestion he cites the observation of 
M. Panas, 7 that the rupture always takes place on the level of the subscapularis. 
He refers also to examples furnished by Berard, 8 Le Dentu, 9 Adams, 10 and 
Korte, 11 in which the existence of the aneurism seemed to precede the attempt 
at reduction. Berard's patient succumbed speedily. Le Dentu's patient, in 
whom scapulo-humeral disarticulation was practised, died also. Adams re- 
duced the dislocation, then tied the subclavian, and the patient recovered. In 
Korte's case the dislocation, caused by a direct blow, was reduced spontaneously. 
An aneurism ensued and the subclavian was tied, but the patient died of sec- 
ondary hemorrhage. Neither of the first three cases, it seems to me, so far as 
their history is related by Poinsot, furnishes absolutely conclusive evidence that 
the rupture did not take place during the preliminary examination. In Korte's 
case one is struck with surprise that a traumatic dislocation should be reduced 
spontaneously. Yet I do not deny that rupture of the axillary artery may in 
some cases result from dislocation. 

Rupture of the Axillary Vein.— Froriep attempted reduction in a woman, 
the dislocation having existed twenty days. The axillary vein was torn entirely 
across, and death ensued in an hour and a half. 12 A woman came under the 
observation of Price 13 who had an old dislocation of the shoulder. Reduction 
having been effected, she died the next day in consequence of a rupture of the 
axillary vein. Hailey 14 reduced a dislocation easily, but two months later a 
tumor appeared in the axilla, the patient succumbed to pyaemia, and the autopsy 
disclosed a rupture of the axillary vein. Professor D. H. Agnew, of the Uni- 
versity of Pennsylvania, ruptured the axillary vein while attempting to reduce 
a dislocation of six weeks. The woman, set. 60 years, had a subcoracoid dislo- 
cation, and while the arm was lifted and extension made according to La Mothe's 
method, the vein was ruptured, causing a very large tumor covering the entire 
breast. Compresses and bandages were at once applied and continued for sev- 
eral weeks, the case resulting in a complete cure, but with the bone unreduced. 15 

Rupture of Artery and Vein. — Platner mentions a case in which death 
ensued from subsequent rupture of the sac. 16 Charles Bell reports a case in 
which the artery was ruptured, at the New Castle Infirmary, and the parts adja- 

1 Malgaigne, op. cit., p. 152. 

2 Memoires sur plusieurs cas de Luxationes, etc. Eepertoire d'Anat. et de Phys., 1827, 
Obs. 3. Four cases of Injury to the Axillary or Brachial Vessels or Nerves. 

3 Warren, Amer. Journ. Med. Sci., vol. xi., N". S., 1846. 

4 Gibson, Elements of Surg., vol. i. p. 824, 4th ed. 

5 St. Barthol. Hosp. Sep., 1866, vol. ii. p. 96. 

6 Med. Times and Gaz., Feb. 1, 1873. 

1 Panas, Bull. Soc. Chir. de Paris, 1877, p. 193. 

8 Berard, Ibid., p. 193. 9 Le Dentu, Ibid., p. 187. 

i° Adams, The Lancet, 1880, vol. ii. p. 260. ll Korte, loc. cit. 

12 Malgaigne, from Froriep. 

13 Price, quoted by Marchand, op cit., p. 63. 

14 Hailey, Brit. Med. Journ., 1863, vol. ii. p. 684. 

15 Agnew, Phila. Med. Times, Aug. 16, 1873- 
36 Malgaigne, Paris ed., 1855, vol. ii. p. 151. 



ACCIDENTS DURING REDUCTION. 591 

cent so much injured that immediate amputation became necessary. It seems 
quite probable, therefore, that the vein was also torn, but this is not stated. 1 

Dr. H. B. Sands, of New York, in attempting to reduce a downward disloca- 
tion of seven or eight weeks' standing, in a lady 86 years of age, found a tumor 
rapidly forming in the axilla, which soon attained the size of a child's head at 
full term; discoloration ensued, and the pulsations of the brachial, ulnar, and 
radial arteries were lost. She was also greatly prostrated. It was evident that 
some vessel had given way, but inasmuch as she finally recovered without any 
surgical operation, it is scarcely probable that it was, as at first suspected, a rup- 
ture of the axillary artery. I ought to add that the patient was, at the time of 
attempted reduction, under the influence of ether, and that great care was said 
to have been exercised by Dr. Sands not to employ great force in the attempt. 
The reduction was not accomplished. 2 

[Dr. Strong reports a case of rupture of both artery and vein during an effort 
at reduction of an old dislocation at the shoulder. The adhesions were first 
thoroughly broken up, and as manipulation failed the operator placed his heel 
in the axilla with a towel over his shoulders, and fastened to the arm. On the 
fourth attempt there was a gush of blood from the axilla. The patient died in 
thirty-six hours, and the autopsy showed rupture of both axillary artery and 
vein. 3 ] 

Cerebral Accidents. — Lisfranc, reports a death from cerebral congestion. 4 
Flaubert 5 in making a second attempt to reduce a dislocation of the shoulder, 
caused what he supposed to be a cerebral hemorrhage. Poinsot, in commenting 
upon these cases, says that the frequency of syncope during the work of reduc- 
tion has been remarked by M. Verneuil ; and that M. Despres and G-osselin have 
thought that dislocations of the shoulder " lend themselves badly " to the use of 
chloroform. Poinsot further suggests that some of these cerebral accidents may 
be due to fatty emboli, or thromboses. 

Injury to Axillary Nerves. — Very many accidents of this kind have hap- 
pened from time to time, some of which have been reported by Flaubert, Mal- 
gaigne, Lenoir, Larrey, Nelaton, Panas, Marchand, Verneuil, and others. 6 

Lesions of trie Soft Parts. — Guerin tore the arm completely from the body, 
in an attempt to reduce a dislocation of three months' standing, in a woman 63 
years of age. 7 Dr. Thomas Smith, 8 of St. Bartholomew, London, saw in a man, 
set. 58 years, the skin and muscles turn until the head of the bone was exposed, 
by simple manual extension with the heel in the axilla. The patient died on the 
ninth day. 

Inflammation, etc. — Hutchinson reported that inflammation, suppuration, 
and death had resulted from an attempt made to reduce an old dislocation of the 
humerus, under his own observation. 9 A like result followed the reduction of a 
recent subclavian dislocation, in the practice of Dr. Courtright, of Ohio. 10 Tre- 
lat's 11 patient died of inflammation caused by attempts at reduction of a subcora- 
coid, incomplete dislocation. The dislocation had existed four months and 
had been subjected to repeated unsuccessful attempts at reduction with India- 
rubber lacs, Jar vis's adjuster, etc. ; and Norris 12 has seen a enormous axillary 
abscess caused by a successful reduction of a dislocation of seven weeks' standing. 
Norris's patient eventually got well. 

Fracture of the Humerus. — An attempt to reduce a dislocation of the 
humerus occasioned a fracture of the surgical neck : M. H., set. 70 years, of 
Brooklyn, N. Y., was admitted into the Long Island College Hospital during 

Willard, Summary of Cases, Phila. Med. Times, Aug. 16, 1873. 

2 Sands, Med. Gaz., March 8, 1880. 

3 Peoria Med. Monthly, Aug. 1888. 

* Malgaigne, Paris ed., 1855, vol. ii. p. 161. 
Flaubert, Marchand, op. cit., p. 106. 

6 Malgaigne, Paris ed., 1855, vol. ii. p. 151. Marchand, op. cit. ; Poinsot, op. cit. 

7 S. Cooper's First Lines, vol. ii. p. 466 ,• Amer. Journ. Med. Sci , 1828, p. 136. 

8 Smith, The Lancet, 1878, vol. ii. p. 3. 

9 Hutchinson, Lond. Hosp. Keports, vol. ii. (Cincinnati Journ. Med., Aug. 1866, p. 361.) 

10 Courtright, Cincinnati Lancet and Observer, Jan. 1877. 

11 Trelat, Marchand, op. cit., p. 114. 

12 Norris, Amer. Journ. Med. Sci., vol. xxxvi. p. 24. 



592 DISLOCATIONS OF THE SHOULDER. 

the spring of 1860. The dislocation had existed six weeks, and was subcoracoid. 
On the day of admission an attempt was made to reduce it, both by Dr. Johnson 
and myself, without an anaesthetic, in which we both failed. I then gave her 
ether, and now discovered that she had a fracture of the second and third ribs 
on the same side. The fractures were ununited. While manipulating, pulling 
the arm gently and rotating, the surgical neck of the humerus gave way. She 
did not survive the injury many days, and the autopsy confirmed this diagnosis. 

In December, 1874, Dr. Stephen Smith, of Bellevue, met with the same acci- 
dent in attempting to reduce a subglenoid dislocation of eight weeks' standing, 
before the class of medical students. The patient, a man about 40 years, was 
under the influence of ether. Manipulation and extension had been freely em- 
ployed in various directions, but the fracture took place when, at my suggestion, 
extension was for a moment relinquished, and while Dr. Smith was rotating the 
humerus with the elbow at a right angle with the body. 

In December, 1865, E. C, set. 32, was admitted to Bellevue with a subcoracoid 
dislocation of the left shoulder. The accident occurred six weeks before. On 
admission, one of the house surgeons attempted reduction, and, as I am informed, 
fractured the surgical neck of the humerus. After which, Dec. 9th, I attempted 
reduction before the class, the patient being under the influence of ether, but 
without success. Malgaigne has recorded four similar cases. 1 Two cases are 
referred to in the Lancet, February 6, 1876 ; one by Howse 2 and the other by 
Sheen 3 ; in the latter of which, however, a suspicion is expressed that the frac- 
ture occurred at the same time as the dislocation. In my opinion the fracture 
was caused by the attempt at reduction. 

Summary. — Rupture of an artery, 28 cases ; most of which were ruptures of 
the axillary artery. Callender, Lister, Blackman, and Korte tied the axillary, 
and the patients all died. The same was the fact in the Sheffield case. Warren 
and Letievant tied the subclavian artery successfully. Gibson, Gunther, and 
Panas, who resorted to the same operation, were unsuccessful. Nelaton tied the 
subclavian, but the result is not stated. Carruther and Bellamy practised dis- 
articulation, and their patients died. Bell did the same, but the result is not 
stated. Eupture of vein alone, four cases. Price, Hailey, and Froriep's patients 
died ; Agnew's patient was saved. Eupture of artery and vein ; this occurred 
in Platner's case, and the patient died. Eupture of unknown vessel, one case ; 
no operation ; recovery. Lesions of the soft parts, two cases. Two deaths. Of 
the whole number, thirty-six, twenty-five terminated fatally; in four the results 
are uncertain, and seven recovered, 

Of fractures of the neck of the humerus I have reported three cases, and I 
have drawn from other sources six cases, making in all nine. My own patient 
died, but probably not in consequence of any injury suffered in the attempt at 
reduction. Norris has reported three cases of ancient dislocation into the axilla, 
treated at the Pennsylvania Hospital; one, of four weeks' standing, was reduced 
in thirty seconds by the aid of pulleys ; the second, which had existed seven 
weeks, was reduced by the same means in about one hour; and the third, dislo- 
cated ten weeks, was left unreduced after extension and counter-extension had 
been made for an hour. In the second case, however, suppuration occurred in 
or about the joint, and, on the tenth day, the abscess was opened, giving exit to 
a large amount of pus. He left the hospital with the parts about the shoulder 
still much hardened and stiff.* 

Dislocations, with Fractures of the Humerus near its Upper End. — 

The older writers, almost without an exception, agree in declaring the 
reduction of these dislocations impossible, until the fracture had united. 
And so late as the year 1828, we have the report of a case treated in this 
manner by a surgeon in Massachusetts. Dr. Warren, of Boston, himself 
reduced the dislocation at the end of four weeks, when the fracture was 

1 Malgaigne, Paris ed., 1855, vol. ii. p. 143. 

2 Howse, The Lancet, 1876, vol. i. p. 212, from Guy's Hosp. Gaz. 1876. 

3 Sheen, Ibid, p. 211. 

4 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 24. 



ACCIDENTS DURING REDUCTION. 



593 




found to have united. 1 But since the introduction of anaesthetics, imme- 
diate attempts at reduction have more often proved successful ; and in 
no case can the surgeon excuse himself for having omitted to make the 
effort. 

Richet reports an example of this kind in a man 68 years of age, in whom the 
dislocation was complicated with a fracture of the neck of the humerus. The 
attempt was not made until the fourth day, 
when it proved successful without extension. 
The fracture was afterward adjusted and con- 
solidated, so that he recovered the complete 
use of his arm. 2 At a meeting of the New 
York Academy of Medicine in May, 1855, Dr. 
Watson reported a case of fracture of the 
humerus near its head, complicated with a 
dislocation into the axilla. The patient was 
a robust man, past middle age, and had re- 
ceived the injury by a blow on the shoulder 
from a steam-engine. He was very much 
prostrated at the time of admission into the 
hospital, and the examination was not made 
until the following morning. The arm was 
then found lying close to the side, but in other 
respects it presented the usual signs of a dislo- 
cation. Ether was immediately administered ; 
and while extension and counter-extension 
were applied, and a sweeping motion given 
to the arm, drawing it from the body, firm 
pressure with the fingers was made in the 
axilla, forcing the head toward the socket, and the bone slipped into its posi- 
tion. 3 

I have reported a case of supposed dislocation, accompanied with a fracture, 
which I succeeded in reducing on the eighth day. 4 I have, however, twice 
failed in attempts to reduce similar dislocations. The first patient, J. B,.. set. 49, 
was admitted to Bellevue Hospital, having received the injury two days before. 
The dislocation was subcoracoid, and the humerus was broken at its surgical 
neck. Having placed him under the influence of ether, assisted by Dr. Stephen 
Smith and several other surgeons of the hospital, I attempted to reduce the dis- 
located bone, but after a trial, prolonged through one hour or more, the effort 
was abandoned. The second case was in a man aged about 40 years, who was 
admitted to Bellevue Hospital in July, 1864, with a dislocation of the head of 
the humerus forward, and a fracture of the surgical neck, of four weeks' standing. 
A surgeon had attempted reduction immediately after the receipt of the injury, 
but had failed. We found the fracture still ununited, and placing him under 
the influence of ether, we tried faithfully, by pushing and pulling, and by 
various other manoeuvres, to reduce the dislocation, but without success. The 
fractures united in both cases promptly, and attempts were subsequently made 
to reduce the dislocation, but to no purpose. 

Examples have been recorded, however, by surgeons, in which the re- 
duction has been accomplished immediately, and without much difficulty, 
by simple pressure upon the head of the bone while the patient was under 
the influence of an anaesthetic, and without the aid of extension ; indeed, 
it is quite doubtful whether extension in these cases is of any service. 
I have already said that I have once succeeded in replacing the head in 



Dislocation of the head, of the 
humerus associated with fracture. 
(Bryant. ) 



1 Boston Med. and Surg. Journ., ~Xo. 1, 1828: also, Amer. Journ. Med. Sci., vol. ii. p. 233. 

2 Kichet, Amer. Journ. Med. Sci., vol. xii., new ser., p. 293, from Bulletin de Therap. 

3 Watson, Amer. Journ. Med. Sci., vol. xvi., new ser., p. 383. 
* Op. cit., vol. ix. p. 93. 



594 DISLOCATIONS OF THE SHOULDER. 

its socket after the lapse of eight days. But if the surgeon were to fail 
by pressure alone, it would be proper to employ extension, especially 
with abduction, and manipulation. 1 In the event of a failure by these 
means, the case ought to be treated as a fracture, and the earliest period 
after the union of the fragments should be seized upon to accomplish the 
reduction of the dislocation. The occasional success of the older surgeons 
by this method is sufficient to warrant the attempt. 

Compound dislocations of this joint will be discussed in a separate chapter 
devoted to the general consideration of compound dislocations of all the joints 
connected with the long bones. 

Dislocations of the Humerus Forward. (Subcoracoid and Sub- 
clavicular.) — The causes of this dislocation are the same as those which 
produce dislocation downward into the axilla, except that it is more 
likely to occur in a fall upon the elbow or upon tbe hand when the line 
of the axis of the- arm and forearm is thrown behind the body. Where 
my records have stated the cause, it has been ascribed to a direct blow 
upon the shoulder sixteen times, and to a fall upon the hand or elbow 
only twice. If it is the result of a direct blow, the impulse has usually 
been received rather upon the back than upon the outer side of the head 
of the humerus ; or the upper end of the bone, having been originally 
thrown directly downward upon the inferior edge of the scapula, may 
have been made to assume the position forward, beneath the pectoral 
muscle, in consequence of the peculiar action of the muscles, or of the 
position of the arm in an attempt to rise. By this latter mode of expla- 
nation, the dislocation forward is consecutive only upon a dislocation 
downward. 

In several instances which have come under my notice the dislocation has 
been due to muscular action alone. In one example the dislocation occurred 
frequently in consequence of epileptic convulsions. This was in the person of a 
lad, set. 18, of a slender frame and feeble muscles. When the dislocation had 
taken place, he was frequently able to reduce it himself; sometimes he was 
obliged to call upon a surgeon, and at other times he left it out a day or two, or 
until it became reduced spontaneously. This spontaneous reduction generally 
took place at night, during sleep. At the time he called upon me the bone had 
been out two days, and he could not reduce it. I administered chloroform, and 
then made repeated and prolonged efforts at reduction, adopting all the usual 
modes of manipulation, but without resorting to mechanical appliances. The 
father now refused to allow me to proceed, and he was taken home with the bone 
unreduced. The following day he called at my office, to say that during the 
night, while asleep, and he thinks, while turning over in bed, the bone suddenly 
resumed its place. 

Drs. E. L. Pardee and G. C. Arnold, of this city, have recently met with a 
case of simultaneous dislocation of both shoulders, in a man aet. 38, caused by a 
fall from his carriage, his arms being extended in front of him, and the force of 
the concussion being received upon his hands. Both of the dislocations were 
subcoracoid ; and they were easily reduced by Dr. Arnold. Surgical writers 
occasionally refer to similar examples, but the number of cases of double dislo- 
cation on record is small. Most of those recorded have happened when the arms 
were extended in front of the body, as in Dr. Pardee's case just cited ; and the 
dislocations were generally subcoracoid. 

1 Hartshorne, Case reduced by Manipulation, Amer. Journ, Med. Sci., Jan. 1855, pp. 
273-4, from Med. Examiner. 



ACCIDENTS DURING REDUCTION. 595 

[J. S. McLaren 1 reports two cases of dislocation at the shoulder occurring 
during sleep. Both cases occurred in Dr. Watson's practice. The first was a man 
about 30 years of age, who awoke one night with an acute pain in his left shoul- 
der, and complete loss of power in the arm. Three months after Dr. Watson 
reduced the luxation with the heel in the axilla. The second was a man under 
40, who by his moans awoke his brother; he had great pain in the left shoulder 
and loss of power in the arm. One month after Dr. Watson, failing to reduce it 
by ordinary means, opened the joint and forced the head from its location under 
the coracoid process into the glenoid fossa with a lithotomy scoop. The capsule 
was torn completely away, and the two upper facets of the greater tuberosity 
had been broken off.] 

Pathology. — The anatomical relations and the various lesions which 
generally -accompany a complete dislocation forward are of two principal 
varieties, differing mainly in the degree or extent of the displacement. 
Thus we may find the head of the humerus resting beneath the coracoid 
process (subcoracoid), having the conjoined tendon of the short head of 
the biceps and of the coraco-brachialis lying upon its anterior surface, 
while its posterior and outer surface rests upon the venter of the scapula 
in front of the glenoid fossa ; in which position it has usually thrust up, 
to a greater or less extent, the belly of the subscapular muscle. 

Sir Astley Cooper, Fergusson, and others, mentioning this form of dislocation, 
call it a "dislocation into the axilla; " by Boyer it is called a "primary luxation 
forward." Dr. Wood, of New York, has reported an example, accompanied 
with a fracture of the neck of the humerus, which he has named " dislocation 
under the subscapulars muscle. The drawing which accompanied the report, 
made from the autopsy, sufficiently shows that it was a dislocation of the same 
character as that which I am now describing. 2 Dr. Parker has called attention 
to a similar case, an account of which was first given in Eeese's edition of 
Cooper's Surgical Dictionary. The head of the humerus reposed in the "sub- 
scapular fossa." 3 By Malgaigne, Vidal (de Cassis), and others, this is called a 
subcoracoid dislocation, a term which, as being more distinctive and appropriate 
than either of the others, I shall choose to adopt. 

In the second variety, the head, having escaped from underneath the 
coracoid process, is made to approach nearer to the sternum, so as to 
apply itself more or less closely to the inferior edge of the clavicle (sub- 
clavicular). In which case the head and neck will be placed behind the 
pectoralis minor, and also behind the short head of the biceps and coraco- 
brachialis ; or between these several muscles on the one hand, and the 
serratus magnus, covering the second and third ribs, on the other hand. 
Upon the appearances which accompany this more advanced form of 
dislocation writers have generally based their descriptions, diagnosis, 
treatment, etc., of forward dislocations. 

In either form of the accident, the deltoid, with the supra- and infra- 
spinatus, is greatly stretched, and the two latter sometimes torn; the 
subscapulars is displaced upward and backward, while its tendon is in 
some instances completely wrenched from the head of the humerus. Mr. 
Erichsen has seen the lesser tubercle Itself completely broken off in two 
examples of this accident which he has been permitted to examine after 

1 Edin. Med. Journ., July, 1889. 

2 Wood, New York Journ. of Med., May, 1850, p. 282. 

3 Parker, Ibid., March, 1852, p. 187. 



596 



DISLOCATIONS OF THE SHOULDER 



death. 1 Occasionally the axillary nerves are carried forward with the 
head of the bone ; and in this case the pain produced by their being thus 
pressed upon is even greater than in dislocations into the axilla. In this 



Fig. 375. 



Fig. 376. 





iubcoracoicl dislocation. 



Subclavicular dislocation. 



accident, as in dislocation downward, the long head of the biceps is some- 
times broken ; the circumflex nerve may be contused or ruptured, and 
the capsule is generally torn very extensively. 

[Mr. Flower 2 affirms, as a result of the examination of numerous specimens 
and reports of dissections, that " the long tendon of the biceps is rarely, if ever, 
injured'' in this dislocation.] 

Symptoms. — If the dislocation is subclavicular (Fig. 376), a depres- 
sion exists under the outer end of the acromion process, extending also 
underneath its posterior margin ; the elbow hangs away from the body, 
and a little backward ; the axis of the limb is much changed, being 
thrown inward in the direction of the middle of the clavicle, the whole 
body inclining moderately to the same side ; there is also more or less 
inability to move the arm, especially in a direction forward or outward ; 
a fulness is seen underneath the clavicle, and to the sternal side of the 
coracoid process, occasioned by the head of the humerus, and the head 
moving with the shaft the arm is lengthened. To these we may add the 
common sign of all dislocations of the humerus, mentioned by Dugas, 
viz., the impossibility of placing the hand upon the opposite shoulder 
while at the same moment the elbow is made to touch the front of the 
chest. If the dislocation is forward, but' subcoracoid, the head of the 
bone will be found below this process and deep in the anterior margin of 
the axillary fossa. It cannot, therefore, be so distinctly felt ; but the 
other signs are the same as in the dislocation forward under the clavicle, 
except that the arm is usually longer than the opposite arm. 

1 Erichsen, Science and Art of Surgery, 2d Amer. ed., p. 250. 

2 System of Surgery, vol. ii. 



ACCIDENTS DURING REDUCTION. 597 

Prognosis. — While on the one hand experience has shown that the 
axillary nerves and artery are less liable to suffer serious and permanent 
injury than in dislocation downward (subglenoid), and that the capsule, 
with the tendinous and muscular tissues about the joint, are no more 
liable to laceration — on the other hand, the difficulty of reduction has 
been often increased, and consequently a large number of examples, in 
proportion to the actual number which occur, have been left unreduced. 

Fig. 377. 




Showing uutorn posterior half of capsule in subcoracoid dislocation of humerus. (Gunn.) 

Dr. Norris relates a case which the surgeon who was first called supposed to 
be a mere contusion, but which, on being admitted to the Pennsylvania Hospital, 
three months after the accident, was found to be a dislocation forward under the 
clavicle. The arm was almost useless. Dr. Norris made extension and counter- 
extension with compound pulleys nearly an hour, but to no purpose ; and finally, 
at the request of the patient, the attempt was given over. 1 

Treatment. — The same rules of treatment which I have established in 
relation to dislocations into the axilla (subglenoid) will be found to be 
applicable to this dislocation ; with the exception that the position of the 
arm in manipulation, or in extension, will be at first somewhat in a line 
backward, and that our efforts will frequently have to be continued with 
more perseverance, although with less fear of injury in consequence of 
supposed adhesions between the artery and the adjacent tissues. The 
extension also must always be made downward and outward, if the dis- 
location is subclavicular, until the head of the bone has escaped from 
beneath the coracoid process ; we may then pull directly outward or even 

1 Norris, Amer. Journ. Med. Sci., vol. xxv. p. 279. 




598 DISLOCATIONS OF THE SHOULDER. 

upward, while at the same moment pressure is made with the hand upon 
the head of the bone in the direction of the socket, and the arm is 
rotated inward. If the dislocation is subcoracoid, our modes of pro- 
cedure need scarcely vary in any respect from those which I have recom- 
mended for dislocation into the axilla. 

Professor Gunn, of Chicago, having in mind the probable resistance offered 
by the posterior and untorn portion of the capsule, directs that, in the subcora- 
coid dislocation an assistant shall fix the shoulder 
Fig. 378. while the surgeon raises the arm to a horizontal posi- 

tion, carries it backward, rotates it externally, and 
draws it into position. 1 

Professor Gunn does not fail to observe, however, 
that this method does not always succeed, owing, as 
he thinks, and as others have suggested before, to the 
fact that the head has slipped through a narrow rent 
in the capsule. The same thing happens occasionally, 
he believes, in other dislocations of the shoulder. 
To shoulder dislocations complicated by this peculiar 
pathological condition, he applies the term " anoma- 
lous." " The escaped head," says Professor Gunn, 
" under such circumstances, would be firmly grasped 
. by the edges of this fissured opening in the capsule, 

\ in such a manner as to foil all mere manipulatory 
A \ efforts. I have three times encountered what I have 

/.'f\ \ considered to be this state of the parts. In one case 

© -•"'" ; v it was my fortune to be able to demonstrate the cor- 

rectness of these views. It was an old forward dis- 
External appearance of location, when, after breaking up the adhesions, I 
a subcoracoid dislocation, was unable to cause the head to reenter the socket. 
(Erichsen.) The uselessness of the arm and the necessity of relief, 

owing to the dependence of a family on this arm, 
induced me to cut down upon the dislocated head, when I found the condition 
above described. I freely divided, with a bistoury, one border of this slit in 
the capsule, and replaced the head in the glenoid fossa." 

While I do not doubt that "buttonholing" the head is sometimes a cause of 
the irreducibility of recent shoulder dislocations by the ordinary methods of 
manipulation, yet it is not plain to me that, in the case of the ancient disloca- 
tion cited, the bands, which being cut permitted the bone to return to its socket, 
were not supplementary or adventitious structures. Nor am I prepared to 
admit that in all recent cases, where well-directed manipulation does not effect 
reduction, the impediment consists solely, or in all cases, in a buttonholing of 
the head. 

The plan adopted in the following case has been found sufficient in several 
examples of subcoracoid dislocation : Mr. McA., of Buffalo, set. 73, moderately 
muscular, fell through a trap-door, striking upon his right elbow, and dislocating 
the humerus forward. Within two hours after the accident, I found the head 
of the bone resting under the coracoid process, where it could be distinctly felt 
and seen. There was a marked depression under the acromion process, and the 
arm was carried out from the body and slightly back. He had not suffered 
much pain. The patient was seated in a chair, and while Dr. Lemon supported 
the acromion process, I pushed the head of the humerus outward toward the 
socket with my left hand, while with my right I pulled gently upon the arm in 
the direction of the axis of the body. After about twenty seconds it slid sud- 
denly into its place with an audible snap. 

Simple manipulation alone will also be found sufficient in many cases of sub- 
clavicular dislocation. S. G., set. 21, fell upon the sidewalk, and dislocated his 
right humerus under the clavicle. We found him about an hour after the acci- 
dent, sitting with his head inclined to his right side, and supporting his elbow 

1 Gunn, loc. cit. 



ACCIDENTS DURING REDUCTION. 599 

with his left hand. A marked depression existed under the outer end of the 
acromion process, and instead of the usual fulness there was a flatness under 
the process behind. The elbow was carried out from the body, and very slightly 
backward. While Dr. Boardman supported the acromion process I lifted the 
elbow from the side, carrying it first upward and backward, and then forward, 
making thus a short detour with the arm, and when the manoeuvre was nearly 
completed the bone slid into its socket with a slight snap. No extension was 
used, and no more force employed than was sufficient to lift and rotate the arm. 
He was not at the time of the reduction faint, nor were his muscles relaxed from 
any other cause. 

More than once I have accomplished the reduction by extension made directly 
upward, as in the following example: A gentleman, 45 years of age, had his left 
shoulder dislocnted forward under the clavicle in a railroad collision. A young 
surgeon had been making extension in various ways for half an hour, when, by 
placing my foot upon the top of the scapula and drawing the arm directly 
upward, I accomplished the reduction immediately and without much effort. 
Six months after the accident, I found the deltoid muscle considerably wasted, 
and he was still unable to raise his arm to a right angle with the body. 

I have in this way also reduced a dislocation which had existed seventeen 
days, the nature of the accident having been misunderstood by the attending 
surgeon. The man was 23 years old, and quite muscular. The dislocation had 
been produced by a severe blow received directly upon the shoulder, and the 
arm was still considerably swollen and very tender. The reduction was accom- 
plished in a few seconds while the patient was under the influence of chloroform, 
by my hands alone, aided only by the pressure of the foot upon the top of the 
scapula. The method adopted successfully in both of the preceding cases, 
namely, pulling directly upward, ought generally to be considered *a last resort, 
inasmuch as it especially exposes the axillary artery, vein, and nerves to injury. 

In December, 1857, Dr. White, of Buffalo, and I, reduced a subclavicular dis- 
location of the right shoulder, which had existed sixty days, in a man 68 years 
of age. The surgeon who first saw the man thought it was only a sprain or a 
severe bruise. When he came to Buffalo, the whole limb was enormously 
swollen, and we had not much expectation of accomplishing a reduction without 
a resort to pulleys and anaesthetics. He w r as, however, placed upon the floor, 
and after extension made for about half an hour, during which time we had 
pulled the arm in various directions, upward, outward, and downward, I at last 
succeeded w T hile my heel was placed in the axilla, and while the limb was under- 
going a slight rotation. No anaesthetic was employed. 

Dr. Cuykendall, of Bucyrus, Ohio, informs me that he has recently reduced 
a subclavicular dislocation on the sixty-fourth day, in a man 62 years old, by 
the following method: "As a last resort I secured the pulleys to the arm above 
the elbow, making the counter-extension with Skey's knob in the axilla, flexed 
the arm and made extension downward and forward ; and when well extended I 
moved his body under the pulley ropes, so as to bring the arm forcibly across 
the breast; then, keeping up the extension, I had Dr. Eichey place his knee 
upon the top of the scapula, and lock his fingers around the elbow, while I 
placed my knee against the elbow and locked my fingers around the top of the 
scapula, and directing the extension removed, we forced the bone upward and 
outward to its sockets;" adhesions were felt to give way, and the restoration of 
the bone w r as found to be complete. It will be understood that this method did 
not succeed until after repeated and long-continued efforts had been made by 
other methods, such as pulling dow r n, pulling out, and pulling directly up. 
Dr. Cuykendall informs me that this is the second time he has succeeded 
in "completing" the reduction of old dislocations of the shoulder by this 
manoeuvre. 

These several cases are mentioned that the surgeon may understand 
how impossible it is always to establish absolute and invariable rules of 
procedure which shall be applicable to every accident of this character. 
The method which will succeed readily in one case may fail completely 
in another, although belonging to the same class, and not apparent!} 7 



600 DISLOCATIONS OF THE SHOULDER. 

differing in its anatomical relations. Before relinquishing the attempt, 
we ought to have put into requisition all the expedients which the expe- 
rience of other surgeons has shown to be worthy of trial. 

During the year 1865, two ancient subcoracoid dislocations came under my 
observation at Bellevue Hospital. One of these cases, in the person of J. T., 
get. 49, had existed two years or more. He was employed about the hospital as 
a carpenter, and had a tolerably useful arm. The second, in the person of E. 
C, set. 32, had existed six weeks when she was admitted. Various attempts had 
been made to reduce the dislocation before admission. During the week follow- 
ing her admission, an attempt was made at reduction by Dr. Verona, an intel- 
ligent house surgeon, subsequently by Dr. James E. Wood, and at the end of 
three months the attempt was made by myself, before the class of medical 
students, the patient being each time under the influence of an anaesthetic. She 
was finally discharged with the bone still unreduced. M. C, set. 46, was ad- 
mitted also to the Charity Hospital, in Feb. 1864, with the same dislocation, 
which had existed six months, having been mistaken at first for a fracture. I 
found her arm free from swelling or paralysis, and moving quite freely in its 
new socket, and declined to make any attempt at reduction. July 28, 1873, an 
Irishman, about 40 years of age, was admitted to St. Francis's Hospital with a 
subcoracoid dislocation of the humerus of eight or nine weeks' standing. The 
surgeon who first saw him believed that he reduced the dislocation, but several 
weeks later he found it was again out of place, and he tried ineffectually to 
reduce it. My own efforts, continued for an hour or more, were equally unsuc- 
cessful. 

The two following cases are recorded in order that they may illustrate the 
apparent inutility of a successful reduction in some cases. W. E. D., of Bridge- 
port, Conn., received a subcoracoid dislocation of the right arm, in consequence 
of a violent and direct blow. Dr. George Lewis, of Bridgeport, a very intelligent 
surgeon, reduced the dislocation within half an hour, the patient being under 
the influence of ether. The restoration of the bone was complete, and attended 
with an audible sound. The arm was subsequently very painful, and at the end 
of three weeks Mr. D. consulted a "natural bone-setter," who manipulated the 
limb violently, and perhaps dislocated it. July 9, 1870, eight weeks after the 
original accident, I found the bone unreduced, and in the presence of a number 
of medical gentlemen at Charity Hospital, effected reduction. The patient was 
anaesthetized, and the reduction was accomplished only after considerable ex- 
tension and manipulation had been practised; the return of the bone to its 
socket being accompanied with a grating sensation. A thick pad was then 
placed in the axilla, and the arm and forearm secured across the front of the 
chest. Mr. D. remained under observation for some time ; but it was soon 
evident that the head of the bone was gradually receding from the socket, and 
that he was not to have a very useful limb. 

Jan. 10,1875, L. B., set. 40, was thrown from a carriage at Norwich, Conn., 
causing a subcoracoid dislocation of the left arm. Five days later Dr. Cassidy, 
of Norwich, reduced the dislocation, the reduction being accompanied with a 
grating sensation. Four days later Dr. Cassidy found the arm again dislocated, 
and he again reduced it. Feb. 11th, thirty-two days after the original accident, 
the arm was examined by myself and other visiting surgeons at Bellevue. Some 
of the gentlemen doubted whether it might not be a fracture of the surgical neck 
of the scapula. In my opinion it was a dislocation. On the same day before 
the class, and under ether, I effected reduction by manipulation, very little ex- 
tension being employed. The arm was, however, manipulated in various direc- 
tions, and considerable adhesions were torn before success was attained, the 
bone returning to its socket suddenly, and with a grating sensation, while the 
heel was in the axilla, and I w T as pulling moderately upon the arm. No one 
doubted the fact of reduction ; the arm was now done up as in the preceding 
case, and the patient remanded to his ward. A few days later I found the head 
of the bone had receded from its socket, and was evidently tending to assume 
the position in which I first saw it; and the motions of the joint were very 
limited. 



DISLOCATIONS BACKWARD. 



601 



It is quite probable that among the successful cases of reduction of old 
dislocations of the shoulder, reported from time to time, many have com- 
pleted their history in a similar manner. Possibly there may have been 
in each of these examples a fracture of the inner lip of the glenoid cavity, 
a condition which has been verified in several autopsies of old shoulder 
dislocation. The rapid changes which often take place in the socket, 
and in the condition of the adjacent tissues, may also account for the 
difficulty which we often experience in reducing these dislocations, and 
of retaining them in place after reduction. In Professor Lister's case, 
already referred to, at the end of seven weeks there was a complete 
socket formed, smooth, cartilaginous, and partly bony ; and strong fibrous 
bands had formed between the coracoid process, the surgical neck of the 
humerus, and the axillary artery, containing a spiculum of bone. 



Dislocations of the Humerus Backward. (Subspinous.) 



Fig. 379. 



jff 



This form of dislocation has been seldom met with. Only two cases, 
according to Sir Astley Cooper, occurred in Gruy's Hospital in thirty- 
eight years. 1 

Sedillot, 2 Malgaigne, Desclaux, 3 Van Buren, 4 W. Parker, 5 Lepelletier, 6 Trow- 
bridge, 7 Physick, Snyder, 8 Stephen Smith, and myself, have each seen one 
example. Examples have also been seen by Dupuytren, 
Arnolt, Best, Levacher, Berard, Fizeau, Velpeau, Fer- 
gusson, Kirkbride, 9 and by Rogers. 10 To these the re- 
searches of Poinsot 11 have added the observations, of 
Lacaussade, Ph. Boyer, Goyrand, Alaboissette, Enright, 
Laugier, Bouisson, Piel, Markham, D. Molliere, Ball, C. 
Perier, Despres, Duplay, Sebilleau, Schmidt, and Tillaux. 

Dr. Stephen Smith's case was seen by myself ten days 
after the accident, by courtesy of Dr. Smith. The patient, 
J. C, set. 36, fell down a flight of stairs, striking on the 
front of his shoulder. A surgeon, who saw him a few 
hours after, thought it was simply a bruise. Sept. 21, he 
was an inmate of Bellevue Hospital. The head of the 
humerus could be distinctly seen in its new position, and 
there was a marked depression under the acromion pro- 
cess, especially in front. The elbow hung very slightly 
from the body, and scarcely more forward than the oppo- 
site elbow. He could carry it forward pretty freely, and 
a little out, but he could not carry it back. He suffered 

very little pain, and there was no swelling of the arm or hand. On the following 
day Dr. Smith reduced the dislocation easily, by pulling the arm forward, and 
at the same time pushing upon the head from behind. Dr. Smith informs me, 
however, that the bone became displaced on the following day ; but that it was 
easily reduced, and afterward remained in place. 




Subspinous dislocation. 



1 A. Cooper, op. cit., p. 352. 

2 Sedillot, Amer. Journ. of Med. Sci., vol. xiii. p. 551, Feb. 1834. 

3 Desclaux, New York Journ. of Med., Nov. 1851, p. 109, from Eevue Medicale. 

4 Van Buren, Ibid., Nov. 1851, p. 110. 

5 Parker, Ibid., March, 1852, p. 186. 

6 Lepelletier, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Arch. Gen., Nov. 1834. 

7 Trowbridge, Boston Med. and Surg. Journ., vol. xxvii. p. 99. 

8 Gibson's Surgery. 9 New York Journ. Med., March, 1852. 

10 Amer. Med. Times, November 9, 1861, vol. v. p. 303. 

11 Poinsot, French ed. of this treatise, p. 860. 



602 DISLOCATIONS OF THE SHOULDER. 

Causes. — One of the patients mentioned in Mr. Cooper's book had his 
shoulder dislocated backward in an epileptic convulsion ; one had fallen 
upon his shoulder ; another met with the accident while pushing a person 
violently with the arm elevated ; and a fourth, seen by Coley, was " pulled 
down by a calf which he was driving, a cord having been tied to one of 
the calf's legs, and being held fast by the man's hand." Markham's 
patient being thrown from his horse and holding upon the bridle with 
his right hand, the arm was drawn forcibly upward. Despres's patient 
had his left arm engaged in the collar of his horse, when the animal 
lifting his head suddenly threw his arm upward. Bell's patient, a minor,- 
get. 18 years, had been caught in an earth-slide when his arm was ex- 
tended upward. My own patient, F. K., had his arm caught in 
machinery on the 14th of January, 1860. The dislocation was discov- 
ered when I was preparing to amputate the arm soon after the accident 
occurred. Pile's patient, a woman, had her arm forcibly twisted by 
her husband during an altercation. Desclaux's patient fell from a 
height with his arm in front of him. The same was the fact with Mol- 
liere's patient, except that the fall was upon the sidewalk. In the case 
seen by Dr. Parker, of New York, a woman, set. 60 years, had fallen for- 
ward and was struck upon the outside of her elbow, arm, and shoulder. 
No attempt was made to reduce it until the fourteenth day, she not 
having for some time called the attention of any surgeon to its condition. 
Trowbridge's patient was thrown from a horse, striking on the palm of 
his hand. With the patient of Perier the dislocation was recurrent, but 
it occurred in the first instance during an epileptic fit. 

Pathology. — Mr. Co©per has given us a careful account of the dissec- 
tion in the case of Mr. Complin, already alluded to, whose arm had been 
dislocated by muscular spasm. This gentleman was 52 years of age, and 
had been subject to epileptic fits, in one of which the shoulder was dislo- 
cated. Many attempts were made to reduce it, but although it seemed 
to be easily drawn into its socket by extension merely, yet, as soon as 
the force ceased, the head of the bone slipped again upon the dorsum 
scapulae, and in this situation it was finally permitted to remain until his 
death, which did not take place until five years after. In the meantime 
he was able to move the limb but very slightly, so that his arm was 
almost useless. Mr. Cooper, to whom the arm was sent after death, found 
the head of the bone resting under the spine of the scapula, and against 
the posterior edge of the glenoid fossa, where it had formed a slight 
depression, and the head itself had become somewhat changed in form by 
absorption. The tendon of the subscapularis muscle and the internal por- 
tion of the capsular ligament were torn at the point where the muscle 
was inserted, but the greater portion of the capsule remained, having 
been pressed back by the head of the bone. The supraspinatus was 
stretched, while the infraspinatus and teres minor were relaxed. The long 
head of the biceps was elongated, but not ruptured. The glenoid fossa 
was rough and irregular upon its surface, the cartilage being absorbed. 
The fact that the bone would not remain in place when reduced was 
explained by the rupture of the subscapularis, and the consequent loss 
of antagonism to the action of the infraspinatus and teres minor. 1 

1 Sir Astley Cooper, op. cit., p. 354. 



DISLOCATIONS BACKWARD 



603 



Laugier, who dissected a recent case, found the tendon of the subscapulars 
torn from its attachment. The same was the fact with the supraspinatus, and 
the head, having passed between the infraspinatus and the teres minor, lay ex- 
posed under the deltoid. In Malgaigne's case the infrascapularis was intact ; 
but the greater tuberosity was torn off, and remained attached to the infra- and 
supraspinatus muscles. The head, having passed between the teres minor and 
the infraspinatus, was situated under the deltoid, below the posterior angle of 
the acromion, one-third of the articular surface overhanging the glenoid cavity. 
Perier dissected the arm of an epileptic woman who had been subject to recur- 



Fig. 380. 



Fig. 381. 





Cooper's ease of subspinous dislocation. Dislocation of the right humerus backward. 

rent backward dislocation. The capsule was not ruptured ; the outer margin of 
the glenoid cavity was partially absorbed ; the head lay slightly overhanging 
the glenoid cavity under the acromion process, and was greatly changed in form 
and texture. Kronlein describes a specimen contained in the Museum of the 
Clinic at Berlin, in which the head had rested just back of the glenoid cavity, 
where it had formed for itself a complete bony socket. 

This case has been regarded by Vidal (de Cassis), Malgaigne, and others, as 
only subacromial, and as a variety of the dislocation backward, differing from 
that in which the head of the bone occupies a position underneath the spine. 
But as I can see no difference except in the degree or extent of the displacement, 
I prefer not to regard the distinction made by these surgeons. 



Symptoms. — The signs of this accident are, a projection under the 
spine of the scapula, produced by the head of the bone, the head being 
obedient to the motions of the arm; a corresponding depression in front 
and under the outer extremity of the acromion process ; a wide space 
between the head of the bone and the coracoid process, into which the 
fingers may be pushed deeply ; the axis of the shaft of the humerus 
directed upward and outward toward a point posterior to the glenoid 
fossa. The forearm is usually carried forward across the chest, and the 
humerus rotated inward, unless the subscapulars muscle is torn. Immo- 
bility exists, but the motions of the arm are not generally so much 
impaired as in either of the other dislocations ; and finally, as in all other 
dislocations of the humerus, the hand cannot be laid upon the opposite 
shoulder while the elbow touches the front of the chest. 



604 DISLOCATIONS OF THE SHOULDER. 

In Parker's case the elbow was thrown outward, although the arm was carried 
very much across the chest. In Stephen Smith's case the arm was nearly verti- 
cal. Desclaux's patient held his hand upon his head, with his arm horizontally 
across his body. In Ball's case the position of the arm was also horizontal. In 
Duplay's patient the arm was hanging beside the body with a slight rotation 
inward, the elbow being carried a little forward. In Markham's patient the arm 
hung beside the body and was immobile. 

Diagnosis. — Usually the diagnosis will be easily made ; in my own 
and Stephen Smith's case the position of the head of the bone was easily 
recognized, but Sir Astley relates one case in which, on the morning 
following the accident, a surgeon was unable to discover the dislocation, 
and on the seventeenth day Bransby Cooper failed to make the diagnosis ; 
nor, indeed, on the twenty-third day, did Sir Astley himself determine 
that it was a dislocation, until he had unexpectedly reduced it while 
manipulating upon the arm. In a second example, Sir Astley at first 
believed it to be a fracture, but a more careful examination showed it to 
be a dislocation backward. In this instance the limb could not be rotated 
outward, as the subscapularis was not torn, and continued to offer resist- 
ance when the arm was moved in this direction ; he was also suffering 
much more pain than did the other patients, owing, as Sir Astley thinks, 
to pressure upon the articular nerves. In the case of Mr. Collinson, 
also mentioned by Mr. Cooper, a surgeon, who saw the patient imme- 
diately after the accident, failed to discover the true nature of the injury; 
and Trowbridge's patient had suffered a dislocation several weeks before 
the nature of the accident was fully determined. In a patient of Sedil- 
lot's, Dupuytren, who was first consulted, thought it was a simple 
inflammation of the joint; and Nelaton related to Panas in 1870, three 
errors in diagnosis committed by surgeons of merit in connection with this 
accident. 

Prognosis. — -In B. Cooper's case the arm was not reduced, and never 
recovered any considerable degree of usefulness. Sebilleau reports a case 
in which the reduction having been attempted fifteen days after the 
accident, proved unsuccessful. Three months later the attempt at 
reduction was repeated by Richet, at Hotel Dieu, but without success ; 
and at the end of four years the arm was nearly immobile, the muscles of 
the forearm and hand being much contracted. Tillaux's patient, set. 59 
years, having a dislocation of six years' standing, which being reduced 
could not be maintained in place, had but limited use of his arm. 
Elevation of the arm was impossible. In Schmidt's case, the dislocation 
was of eighteen years' standing, and the motions of the arm were almost 
completely restored. Mr. Collinson's arm, reduced on the second day. 
was restored to all its functions within one month. Dr. Parker's patient 
had nearly recovered the complete use of her arm at the end of four 
weeks, although it was not reduced until it had been out fourteen days. 
Sedillot succeeded in reducing the dislocation in the case of his patient, 
at the end of one year and fifteen days; Lepelletier, after forty-five 
days ; Trowbridge, after forty days ; and in this latter case we are 
informed that the arm was restored to usefulness. 

Treatment. — In the first case mentioned by Sir Astley Cooper, "the 
bandages were applied in the same manner as if the head of the humerus 






DISLOCATIONS BACKWARD. 605 

had been in the axilla, and the extension was made in the same direction 
as in that accident " (downward and a little outward). In less than five 
minutes the bone slipped into its socket with a loud snap. The second 
case was treated successfully in the same way. Mr. Dunn also having 
failed to reduce by pulling upward, finally succeeded by pulling at the 
wrist downward and forward, while an assistant pushed the head of the 
bone toward the socket ; the heel was not placed in the axilla, which 
Mr. Bransby Cooper thinks would have only retarded the reduction. 
Stephen Smith succeeded by a similar manoeuvre. Mr. Key also failed 
to accomplish reduction while carrying the arm upward and backward, 
but when the patient had become faint, by placing the heel in the axilla 
and pulling downward a minute or two, the bone was reduced. Vidal 
(de Cassis) recommends the same plan, namely, that we shall pull in the 
direction in which we find the limb ; Trowbridge employed the pulleys 
successfully, the extension being made downward and forward ; while 
Dr. Parker succeeded equally well with his patient, by " pulling the 
arm outward, downward, and slightly forward." Counter- extension was 
at the same time made by a sheet in the axilla, and the head of the 
humerus was pushed toward the socket by the hand. In Mr. Collinson's 
case, the scapula was supported by a towel, while "gradual extension of 
the limb was made directly outward, and then the arm being moved 
slowly forward, the head of the bone was distinctly heard to snap into 
its socket." The time occupied was not more than two or three minutes. 
Rogers succeeded by N. R. Smith's method. Sir Astley, how r ever, 
seems to give the preference to the method which succeeded so happily 
in the case of Mr. Gr., while he was still manipulating with a view to 
determine the character of the accident. " I readily reduced the bone," 
he remarks, " by raising the hand and arm, and by turning the hand 
backward behind the head." In one other instance, having failed to 
reduce it by slight extension outward he raised the arm perpendicularly, 
at the same time forced it backward behind the patient's head, and the 
reduction was promptly effected. Markham succeeded by a similar 
manoeuvre. In the case of Kretner, I first attempted reduction by pres- 
sure directly upon the head of the humerus ; but failing, I proceeded to 
pull the arm with moderate force outward and downward, which pro- 
cedure was attended with immediate success. The patient was under the 
influence of chloroform. Slight forward traction was sufficient in the 
case of Duplay. Moliere combined direct pressure upon the head with 
slight extension. Arm. Depres succeeded by traction made at a right 
angle with the body, combined with moderate rotation. 

Prof. Gunn, in describing the specimen from which the accompanying illus- 
tration is taken, remarked : "It is seen that the head rests on the dorsum of the 
scapula, while the vacated glenoid cavity is covered by the untorn anterior half 
of the capsular ligament, which is stretched across the articular surface, holding 
the head snugly against the posterior edge of the fossa, and by its inferior fibres 
causing the advanced position of the lower end of the humerus, which is so 
characteristic of the accident. Internal rotation relaxes this untorn portion of 
the ligament, as does also a still more advanced position of the elbow with the 
humerus elevated to a horizontal position. For a reduction of this luxation the 
shoulder should be properly fixed by an assistant, while the surgeon seizes the 



606 



DISLOCATIONS OF THE SHOULDER. 



arm by the elbow and forearm, raises it to a horizontal position, carries it to the 
front, rotates inwardly, and draws it into place." l 

After the reduction, a compress should be placed against the head of 
the bone, and underneath the spine of the scapula, and this should be 
secured in its place by several turns of a roller. The forearm ought also 

Fig. 382. 




Showing untorn anterior half of capsule in dorsal dislocation of the humerus. (Gunn.) 

to be placed in a sling, with the elbow thrown a little back of the centre 
of the body,, so as to direct the head of the humerus forward. 

Dislocations of the Humerus Upward. — The existence of this form of 
dislocation, unaccompanied with a fracture of the coracoid or acromion 
processes, or of both, has been denied by Boyer, Sedillot, and most other 
surgical writers. A certain number of facts and observations, however, 
tend to establish its possibility or its actual occurrence. 

Malgaigne, 2 who was the first to admit of its possibility, says : " A man, set. 68, 
was seated upon a wagon loaded with fagots, when the wagon was overturned. 
He was thrown a great distance, and struck upon the point of the shoulder, with 
the arm against the side of the body. The man immediately experienced a 
sharp pain, and it was impossible to move the arm. A bone-setter made violent 
tractions, and sent him away with his arm in a sling. Eight days after he tried 
to move it, but without much success ; and he came to consult me at the end of 
two months and a half. The head of the humerus was dislocated forward and 
upward above the acromio-coracoid ligament, corresponding outward to the 
internal border of the acromion, covering inward the coracoid process, and rest- 
ing above against the inferior surface of the clavicle, raising the deltoid muscle 
to such an extent that a pin inserted into the most projecting part did not show 
more than eight millimetres of flesh ; while the pectoralis major and the deltoid 
were six millimetres from the surface. The arm was not shortened more than 
half a centimetre. I attempted reduction by elevating the arm to a right angle, 



Gunn, loc. cit. 



2 Malgaigne, op. ci*-., vol. ii. p. 530. 



DISLOCATIONS UPWARD. 



607 



Fig. 383. 



at the same time pressing on the head to push it downward, outward, and back- 
ward, while an aid tried to press the acromion upward, inward, and forward. 
At 205 kilogrammes I heard a cracking as if a bone had been broken, although 
the reduction did not seem to have been effected. I ceased traction, and explored 
all the points of the shoulder without discovering any fracture. There did not 
even ensue any sensible tumefaction. The head was more movable, and it was 
possible to draw it downward until the fingers could be laid in the space thus 
created below the clavicle. There was also some gain in the freedom and extent 
of the movements. I thought of dividing the acromio-coracoid ligament, but 
after some reflection I judged it preferable not to do so." 

According to Poinsot, similar examples have been reported by Verneuil, Le 
Dentu, Busch, Laugier, Chassaignac, and Denonvilliers. Verneuil and Le Dentu 
were unable in their patients to find a fracture of the coracoid process. The 
same was the fact with Busch; while Laugier, Chassaignac, and Denonvilliers 
are silent upon this subject. In the case seen 1 by Busch, the patient, while 
holding the reins of a restive horse, seized the bit with his right hand, when the 
horse rearing struck the shoulder with its foot at 
the antero-internal portion of the scapulo-humeral 
region. In Laugier's case, a lad, 16 years old, 
having his arm stretched out and fixed on a 
machine, with his body resting on his arm, and 
his feet far from the resting-point, felt suddenly 
a violent torsion of the body from before back- 
ward, and from right to left. M. Poinsot thus 
explains the mechanism of the accident in this 
case: " In that movement, the head of the hume- 
rus, on which the body rotated, underwent a 
movement of rotation outward, being carried at 
the same time upward and forward, so as to cor- 
respond to the superior and anterior part of the 
articular capsule ; which latter being torn where 
it was stretched, the bone was permitted to go up- 
ward, so as to place itself outside the beak of the 
coracoid apophysis." 

In a case seen by Holmes, 2 the patient, a man, 
60 years of age, had fallen a great height (about 
30 feet) upon a pile of stones, striking upon the 
head, the left side of the body, and the left elbow. 
When brought to St. George's Hospital, his uncon- 
sciousness, indicating cerebral concussion, rendered 
it necessary to postpone the reduction for several 
days. When it had been decided to attempt it, 
he was taken with septicemic symptoms, which originated in a compound frac- 
ture of the elbow, and he died fifteen days after the accident. On examining 
the dislocated shoulder, the head of the humerus was found immediately under 
the skin, with the cephalic vein at its internal portion. It had fractured the 
coracoid apophysis in its movement from below upward, and was resting behind 
on the projection of that apophysis and on the clavicle, pulling with it a small 
portion of the acromio-coracoid ligament which had not been torn. At its 
internal portion, besides a few fibres of the deltoid and of the cephalic vein, the 
fractured extremity of the coracoid process was found, with the muscles which 
are inserted in it : the pectoralis minor, the coraco-brachialis, and the short 
portion of the biceps. At the external portion and a little backward was the 
acromion, separated from the head by a few fibres of the deltoid. Below and a 
little outside was the glenoid cavity, whose superior border was situated entirely 
below the level of the humeral extremity. The tendon of the longer portion of 
the biceps was still attached to the scapula, and was consequently situated below 
and outside of the dislocated head, which, as it came out of its socket, had 
slightly torn this tendon, so that a few of its internal fibres had been separated 




Busch' 



case, supra-coracoid 
dislocation. 



1 Busch, Arch, fur Win. Med., Bd. xix. Hft. 3, p. 400. 

2 Holmes, Med.-Chir. Trans., vol. xli. 



608 



DISLOCATIONS OF THE SHOULDER. 



from the muscle, and remained floating freely, with a cluster of muscular fibres 
attached to them. The coracoid apophysis had been fractured near its base, the 
coraco-acromial ligament remaining attached to the two fragments, so that they 
could not be much separated from each other ; the summit was pulled from 
above downward, and from out inward, by the muscles inserted in it. The 
humeral head rested directly on the projection of the apophysis, which had pro- 
duced a slight erosion on the corresponding articular cartilage. The humerus 
had slightly turned on its axis, so that the greater tuberosity was relatively more 
in front than in its normal position. The subscapulars muscle was intact. The 
muscles inserted into the greater tuberosity had been lacerated, except a portion 
of the teres minor, which had remained uninjured; the capsular ligament, torn 
at its superior and internal portion, presented a large opening which had given 
passage to the head. 

Albert, 3 of Innsbruck, has reported a case of double dislocation upward, in a 
man 60 years old, which had existed many years. This man having died of 
pneumonia, an autopsy was obtained. All that was known about the origin of 
the dislocation was, that it was caused while he was trying to hold a pair of 
spirited horses by the bridle. 

The following condition of the parts was found at the autopsy : 
" Left Shoulder. — After the removal of the skin, the great pectoral muscle was 
seen gathered on itself, from below upward, so that its vertical diameter, on a 
level with the mammary line, was ten centimetres long ; the fan-like direction 
of its fibres at the level of its insertion being consequently far more noticeable 
than in the normal state. The deltoid was very much stretched in its middle 
part, and was relaxed, on the contrary, in its scapular portion. In the move- 
ments of slight abduction, the great pectoral and the teres major muscles were 
stretched and resisted the effort. The deltoid being detached at its inferior 
insertion, a small independent subdeltoid bursa was found; the subacromial 
bursa, situated more backward and small, presented on its internal surface 
papillary vegetations. After removing the great pectoral, at the inner side of 



Fig. 384. 



Fig. 385. 





Albert's case of double upward dislocation. 



Front view. 



Side view. 



the humerus, the coraco-brachialis and the smaller portion of the biceps were 
found intact, as well as the plexus and the vessels which were also situated at 
the inner side of the bone; the tendon of the longer portion of the biceps could 
be followed to the inferior limit of the surgical neck, where there existed a bony 
prominence, which we shall mention further on ; but the tendon ended there by 
a sort of swelling ; the bicipital groove was no more distinguishable. The cap- 
sule., of medium thickness, was inserted into the whole circumference of the 



i Albert, Wiener med. Blatter, 1879, xix..S. 453. 



ACCIDENTS DURING REDUCTION. 



609 



anatomical neck; on a level with the humeral head it adhered also to the 
articular surface; looking downward and backward to its central insertion, the 
capsule presented in front and above a considerable enlargement of its cavity so 
as to touch the lateral part of the coracoid apophysis, and it was attached to the 
edge of the acromio-coracoid ligament. The acromio-coracoid, the trapezoid, 
and conoid ligaments were intact. The humeral head overlapped, by its superior 
third, the edge of the acromio-coracoid ligament, but could easily be pushed 
upward, into the space comprised between that ligament, the acromion, and the 
coracoid processes, so as to overlap the ligament by all its superior half when 
the humerus was carried outward and backward. The glenoid cavity was filled 
with cellular tissue, which on a level with the margin presented a highly-polished 
surface. From the inferior edge of the surgical neck to the head of the humerus, 
was a bony lamella, starting from the postero-lateral part of the bone and termi- 
nating backward by a very irregular free edge. From the base of the coracoid 
apophysis a very nodulated bony prominence was detached, its shape being that 
of a crow's beak, or rather a deer's horn, and measuring two centimetres and a 
half in length. 

"Bight Shoulder. — The muscles, the large vessels, the acromio-coracoid, conoid, 
and trapezoid ligaments, as well as the scapula and the humerus, were all in their 
normal state. The acromial extremity of the clavicle was enlarged, with a flat- 
tening of the portion corresponding to the head. The capsule presented the 
appearance of a large sac with walls very much thickened at certain points. In 
the part corresponding to the superior margin of the glenoid cavity were a num- 
ber of superposed horizontal folds, of the size of a centimetre, and projecting 
into the interior of the cavity; these folds divided it into two portions, an infe- 
rior one, corresponding to the old articular cavity, and a superior one, corre- 
sponding to the new one. The head could be abnormally moved in all directions 
within the capsule, and it appeared flattened above and behind and was denuded 
of its cartilage. On the level of the anatomical neck, the cartilage was worn 
out in places; in others it presented a velvety alteration, at which points it was 
of a yellowish-gray color. The bicipital groove was very shallow." 

Panas and Angers 1 have demonstrated upon the cadaver that the head of the 
humerus could be dislocated upward above the acromio-coracoid vault without 
destroying it. 

Fig. 386. 




Robson's case of supracoraeoid dislocation of humerus. Posterior view. (Robson.) 

[A. W. M. Robson, of Leeds, reports a case of supracoraeoid dislocation of the 
shoulder: A boy, eet. 16, was putting on his coat, and having got his right arm 
into the sleeve, was commencing to introduce the left, when the loose sleeve was 
caught by the "breast-strap" of the machinery and quickly twisted round, the 
right arm being pulled violently in an upward and backward direction, away 



Panas, Art. Epaule, Nouveau Diet, de Med. et de Chir. Prat., t. xiii. p. 466. 

39 



610 



DISLOCATIONS OF THE SHOULDER. 



from the body. A sudden pain was felt in the shoulder at the time, but after- 
ward the whole arm felt numb, although on touching it or on attempting to raise 
it there was very acute pain. Six weeks after the accident there was a large, 
hard, slightly-irregular, rounded swelling about a finger's breadth in front of 
the right acromion and immediately to the outer side of the coracoid process. 
In front a depression was seen immediately beneath the acromion, and again 
below this a rounded elevation; the bony prominence moved with the shaft of 
the humerus in flexion, extension, adduction, abduction, etc., so that there was 
no doubt that it was the head of the bone. The arm could be readily placed 
against the side of the chest, with the hand touching the opposite shoulder and 
the tips of the fingers on the occiput. The arm could be moved anteriorly to the 
angle of forty-five degrees, and was then arrested by the contact of the head of 
the bone with the acromion ; backward movement not limited. Rotation outward 
was prevented by the head of the bone coming in contact with the acromion. 
Efforts at reduction failing, an incision was made on the outer side of the 
shoulder, disclosing a longitudinal fracture separating the greater tuberosity 
and extending down the shaft; the fossa being filled with plastic material, the 
operation was discontinued. The patient recovered good use of the arm. 1 

Dr. Charles A. Powers, of New York, 2 reports a case of dislocation of the 
right humerus of long standing, accompanied by exceptional displacement, 
which is evidently allied to the upward displacement, though it had other 
features quite anomalous. The patient was a man, set. 20, and the displacement 
had existed three years. In October, 1886, his arm and forearm were caught in 
machinery in such a way that he was thrown forcibly against it, the forearm 
being violently wrenched and the shoulder contused. Pain and disability of 
the shoulder followed. Three months after, reduction, under ether, was at- 
tempted, but the bone could not be retained in place, and he resumed his work 

Fig. 387. 



11 



Powers's case. Anterior view. 

— brush-making. He was next examined December 1, 1889, by Dr. Powers, 
when an anterior dislocation of the humerus was detected, the head of the bone 
resting above and in front of the glenoid cavity ; the deltoid was extremely 
atrophied; the humerus could be made to undergo complete internal rotation, 
but external rotation was a little restricted; abduction was possible to but forty- 
five degrees. When the arm was lifted the head of the humerus could be made 
to undergo a very marked excursion forward and upward, resting without and 
above the coracoid process (Figs. 387 and 388), and could be forced to lie 
entirely above the clavicle. On bringing the elbow to the side, twenty degrees 
in front of the mid-axillary line, the head of the humerus could be forced into 
the glenoid cavity, or rather to a glenoid position, but when the force was 



Annals of Surgery, vol. viii., 1888. 
Medical News, Sept. 1, 1890. 



ACCIDENTS DURING REDUCTION. 



611 



released it would at once fly forward. When the elbow was at the side, and the 
head dislocated forward, the right hand could easily be placed on the opposite 
shoulder. The axillary acromial measurement was three-quarters of an inch 
greater than that on the opposite side. The functions of the hand and forearm 
were excellent. The entire head, tuberosities, and neck of the bone could be 
intelligently palpated. At the inner side of the neck a prominent ridge could 

Fig. 388. 



Powers's case. Lateral view. 



be distinctly felt, and the presence of this raised the question of longitudinal 
fracture at the time of the original injury. Dr. Powers states that "it would 
seem highly probable that the patient suffered, at the time of his accident, an 
anterior luxation, probably complicated by a longitudinal fracture through the 
upper part of the bone, and that constant use of the arm enabled the head of 
the humerus to make its wide excursion inward and upward." 

The possibility of this form of dislocation without fracture is now definitely 
established by dissection. Additional cases show, however, that some form of 
fracture generally exists. In Robson's case a longitudinal fracture separated 
the greater tuberosity, while the existence of a fracture, longitudinal in its direc- 
tion, was believed to exist in Powers's case.] 

It may be here stated briefly, by way of summary, that the testimony 
which is to establish the possibility of this accident unaccompanied with 
a fracture, is found in seven clinical cases not verified by an autopsy, in 
certain experiments made upon the cadaver, and in the single case re- 
ported by Albert, and demonstrated by a dissection. With the imperfect 
knowledge in my possession relative to the purely clinical cases, I am not 
warranted in subjecting them to criticism. As to the value of Panas's 
experiments made upon the cadaver, I must repeat what I have often 
said before in reference to similar experiments made upon other joints. 
The results of such experiments cannot be applied without great reserve 
to dislocations occurring upon the living subject, and when the muscles 
have their normal power and activity. Of the case of the man set. 60, 
reported by Albert, and in which case alone has a dissection revealed a 
dislocation without a fracture, the fact that it existed in both shoulders 
at the same time, connected with the obscurity of its history, suggests the 



612 DISLOCATIONS OF THE SHOULDER. 

possibility that, instead of having been primarily a dislocation, it was at 
first only a sprain, from which resulted an arthritic and muscular affec- 
tion, in consequence of which latter conditions the displacement had 
gradually been produced. 

The following remarks are quoted from Poinsot, who accepts the dis- 
location as an established fact : 

" Prognosis. — In all cases of absolutely recent dislocation, and where reduction 
has been effected without great efforts, the prognosis is possessed of little gravity ; 
but it soon becomes very serious, both on account of the extreme hindrance 
resulting from the persisting displacement and of the infinite, if not insur- 
mountable, difficulties which are met with during the attempts at reduction 
after a certain lapse of time. Laugier, on the twelfth day, could not reduce the 
dislocation in his patient; Malgaigne, after two months and a half, and Busch, 
after five months, were also unsuccessful. Professor Verneuil, it is true, was 
able to effect reduction on the thirty-sixth day, but it was a dislocation which 
had already been reduced on the very day of the accident, and which had been 
reproduced. 

" Treatment. — Malgaigne, in the case of his patient, had attempted reduction 
by making tractions upon the arm elevated at a right angle, and by pressing 
upon the head in such manner as to push it downward, outward, and backward, 
while an assistant tried to pull the acromion upward, inward, and forward. 
Busch employed, without being more successful, Schinzinger's procedure (rota- 
tion outward), and that of A. Cooper (elevation of the arm at different degrees). 
Denonvilliers and M. Verneuil effected reduction by means of tractions down- 
ward, combined with a tilting motion, with the view of bringing back the head 
toward the cavity. M. Verneuil had failed the first time, when tractions down- 
ward were made alone, and, during his second attempt, he thought it necessary 
to anaesthetize the patient. M. Panas, being guided by experiments, advises 
'to carry the arm away from the body until the head is sufficiently lowered to 
pass under the coracoid ; at the same time that the elbow is being raised, it is 
necessary to give the humerus a movement of rotation inward, gradually in- 
creased.' Albert, of Innsbruck, recommends abduction, extension backward, 
and rotation inward. Verneuil, in order to prevent the dislocation from being 
reproduced, as had already happened twice, placed the arm (strongly adducted) 
in front of the chest, the hand being placed upon the sound shoulder, and main- 
tained in that position by means of a silicate bandage." 



Partial Dislocations of the Humerus. 

The existence of this or of any other form of partial dislocation of the 
shoulder-joint, as a traumatic accident, has not up to this moment been 
fairly established. The anatomical structure of the joint renders its 
occurrence exceedingly improbable, if not absolutely impossible. 

The only example mentioned by Sir Astley Cooper, in which a dissection 
was made, showed that the long head of the biceps had been ruptured, and that 
the capsule was torn, while the head of the humerus was resting under the cora- 
coid process. We shall have no difficulty, therefore, in assigning it to its proper 
place as a complete subcoracoid dislocation. In Mr. Hargrave's case, also, the 
tendon of the biceps was torn ; while Dupuytren omits to mention what was the 
actual fact in relation to this tendon in the case seen by him, but it is distinctly 
stated that the head of the bone rested upon the ribs. Mr. Hargrave seems, 
therefore, to have described a case of rupture of the long head of the biceps, and 
it is possible that Dupuytren, who knew nothing of the previous history of the 
subject, has given us a faithful account of a pathological dislocation, a result of 



PARTIAL DISLOCATIONS OF THE HUMERUS. 



613 



disease, and not of a direct injury. Poinsot remarks, also, that the four cases 
mentioned by Owen 1 were examples of chronic lesion. 

If the head of the humerus is driven from its socket by violence, and 
remains thus displaced, it is a complete dislocation ; since it is only by 
having placed the semi-diameter of the head of the bone outside of the 
margin of the glenoid fossa that it can be made for one moment to retain 
its abnormal position. To accomplish this amount of displacement 
upward, or upward and forward, or directly forward, the acromion or 
the coracoid process must be broken ; while its occurrence in any other 
direction must involve at least a most extraordinary extension, if not an 
actual laceration, of the capsule. If we admit, with Malgaigne, that 
occasionally the capsule has been found capable of such extraordinary 
extension without actual rupture, I am still unwilling to regard this as a 
fair example of a partial dislocation, since the head of the bone no longer 
moves in its socket, being at no point in actual contact with the articu- 
lar surface of the glenoid fossa. It is 
essentially a complete dislocation, ac- 
cording to all the admitted definitions 
of this term. 

It is quite probable that a majority 
of these accidents were examples of 
rupture or displacement of the tendon 
of the long head of the biceps, the 
eifect of which, as Mr. Jno. G. Smith 2 
and Mr. Soclen 3 have shown by a num- 
ber of dissections, is to allow the head 
of the humerus to be drawn upward 
and forward in its socket, until it is 
arrested by the two processes, and by 
the coraco-acroruial ligament. Says 
Mr. Soden : "To enable the bone to 
maintain its equilibrium, it is neces- 
sary that the capsular muscles should 
exactly counterbalance each other ; 
and as there is no muscle from the ribs to the humerus to antagonize 
the upper capsular muscles" (that is, to draw the head of the humerus 
downward), "it is suggested that this office is performed by the singular 
course of the long tendon of the biceps, which, by passing over the head 
of the bone, when the muscle is put in action, tends to throw the head 
downward and backward ; it follows, therefore, that, the tendon being 
removed, the head of the bone would rise upward and forward." 

The head of the humerus sometimes remains for a long time after the 
reduction has been effected slightly advanced in its socket, so as to lead 
to a suspicion that it is not properly reduced. 




Soden's case of displacement of the long 
head of the biceps. 4 



1 E. Owen, The Lancet, 1875, vol. i. p. 759. 

2 Amer. Journ. Med. Sci., vol. xvi. p. 219, May, 1835, from London Med. Gaz. 

3 Ibid., vol. xxix. p. 489, from Lond. Med. Gaz., July, 1841. 

4 Pirrie's System of Surgery, Amer. ed., p. 255 ; also Sir Astlev Cooper, edited by Bransby 
Cooper, Amer. ed., p. 363. 



614 DISLOCATIONS OF THE SHOULDER. 

The same thing, also, has been noticed by me occasionally where the 
shoulder had been subjected to a violent wrench, but no actual disloca- 
tion had ever occurred. In either case the explanation is perhaps the 
same — the long head of the biceps has been broken or displaced ; or, 
when it follows a dislocation, some of the muscles inserted into the greater 
tuberosity have been torn from their attachments. 

In these circumstances we may find a sufficient and perhaps the most frequent 
explanation ; yet it is quite probable that, in a considerable number of cases, the 
laceration of the capsule, and the action of the muscles, are alone concerned in 
the production of this phenomenon. I have seen one example in the person of 
Mr. Craig, of Brooklyn, in which the tendon of the biceps suddenly resumed its 
position after the lapse of several days, and the promineuce of the head of the 
humerus at once disappeared. David Prince, 1 Hewitt, 2 and Holmes* have re- 
ported similar cases. In Mr. Holmes's case, however, the coracoid process was 
broken also. 

Dr. Mercer, of Syracuse, N. Yv, relates several examples of forward displace- 
ment after injuries to the shoulder-joint, one of which is exceedingly pertinent. 
Mrs. B., a well-developed woman, of full habit, aged 56, seven years since was 
thrown from a carriage, dislocating her right shoulder, which was reduced a 
short time after the accident, but the shoulder was painful, and tender to the 
touch, and almost useless for months after. She could carry the arm forward 
and backward, but could not raise it from the side, or carry her hand behind 
her, or raise it to her head, for fourteen months. She has gradually gained 
better use of her arm, but now she cannot raise her elbow from the side more 
than half-way to a horizontal position without assistance ; but with assistance, 
the arm may be carried into any position without pain or resistance. Measure- 
ment shows no appreciable difference in the size or length of the arm, or size of 
the shoulder; but the point of the shoulder is still tender to the touch, is prom- 
inent in front, and correspondingly flattened behind. The head of the humerus 
appears to rest against the outside of the coracoid process, but the fulness of 
habit obscures the diagnosis, compared with other cases. Several doctors, at 
different times, have examined the shoulder; some have said it was not properly 
reduced, and advised a suit for malpractice. " I examined the shoulder again 
in November last; it presented the same general appearance, although the 
patient was much thinner in flesh from recent sickness. Some six weeks previ- 
ous to this examination, in a sudden and thoughtless effort to raise the arm 
above the head, the muscles unexpectedly obeyed the will ; since which time 
she has had perfect use of it, though the deformity still remains. She thinks 
she felt or heard a snap when the arm went up, but it was followed by no pain, 
soreness, or swelling." 4 

There cannot be much doubt, I think, that in this case, at least, the deformity 
and maiming were due in a great measure to a displacement of the long head of 
the biceps. 5 

[The frequency with which the long tendon of the biceps is displaced or 
ruptured is very doubtful. Recent investigations seem to show that it is a com- 
paratively rare accident.] 

If a displacement of the tendon necessarily causes a displacement of 
the head of the humerus, it might seem proper to infer that a rupture 
of the tendon would do the same. The only example of rupture of the 
tendon which has come under my observation does not confirm this 
opinion. 

1 Prince, St. Louis Med. and Surg. Journ , Nov. 1879. 

2 Hewitt, Holmes's Surgery, 2d Lond ed., vol. ii. p. 820. 
s Holmes's Surgery, 2d Lond. ed., vol. ii. p. 820. 

4 Mercer, Buffalo Med. Journ., vol. xiv. p. 641, April, 1859. 

5 Broomfleld's Chirurg. Observ., vol. ii. p. 76. 



PARTIAL DISLOCATIONS OF THE HUMERUS. 



615 



J. W., set. 46, a sailor, and a man of remarkable muscular development, while 
pushing a swing with his arms extended felt something snap in his right arm, 
and the arm at once became powerless. The sensation of snapping was at a 
point about four and a half inches below the acromion process. The pain was 
like that caused by hitting a nerve ; on the following day there was an extensive 
ecchymosis over the upper end of the humerus, and the belly of the biceps was 
full and flabby. He was examined by me about eight months after the injury. 
The belly of the biceps had shortened upon itself, and made a remarkable prom- 
inence on the front of the arm, but he could not render it firm by contraction. 
He could flex the arm slowly, but not against any considerable resistance. The 
head of the humerus was not advanced in the socket. I could feel the tendon 
of the biceps in its groove, and inferred that the rupture took place near its 
insertion into the muscle. J. L. Petit has reported a similar case, in which the 
rupture was caused by the extension employed in an attempt to reduce a dislo- 
cation of the arm. 1 Poinsot records an example of rupture of this tendon in a 
man, caused by lifting, and in which the head of the humerus was not displaced. 
Three weeks later the same accident was reproduced in a similar manner. 

Dr. Gerster, in a paper on "Subcutaneous Injuries of the Biceps Brachii," 2 
has made the following historical notes and observations: "Older surgeons 
(Stanley, Bromfield, Knox, Monteggia, for instance), up to the middle of this 
century, diagnosed as dislocations of the long head of the biceps, cases similar 
to the one related" (case of partial rupture of the tendon, and of the corre- 
sponding part of the sheath of the long head of the biceps). "They supposed 
that the tendon left its groove, and slipped upon the major tubercle. True, 
none of them ever found the tendon in its dislocated condition, but they 
assumed that a spontaneous reduction took place by a rotation of the humerus, 
before a competent judge could ascertain the nature of the injury. William 
Cooper and Boerhaave accepted the possibility of such an injury. Fergusson 
expressed himself cautiously on the subject. Bardeleben, Pitha, and Volkmann 
deny its existence, referring to a series of exhaustive articles in the Gazette 
Hebdomadaire (2d ser., [xiv.], 21, 23, 25, 1867), written by Jarjavay, which com- 
pletely disposes of this ' mysterious dislocation,' as Pitha sarcastically calls it.'' 
Gerster states, moreover, that Pouteau had long before doubted the existence of 
this dislocation, and that Malgaigne had expressed scepticism as to the true 
character of Mr. Soden's case. In short, Dr. Gerster claims that its existence, 
uncomplicated with other accidents, has never been demonstrated satisfactorily 
upon the living or dead subject ; and that, to say the least, it is doubtful whether 
it has ever occurred. The entire argument, together with the anatomical reasons 
assigned, are very ingenious; and while they do not settle conclusively the ques- 
tion of its possibility, they seem to throw a doubt upon the true nature of some 
of the cases reported. 

Dr. White, 3 of Philadelphia, in an excellent resume of this subject, concludes 
that the occurrence of a traumatic dislocation of the long tendon of the biceps, 
unaccompanied with a dislocation of the humerus, has not been absolutely 
proved. He reports, however, a case which both Dr. Agnew and himself 
believed to be such a dislocation. A man, set. 37, had fallen upon his shoulder 
from a considerable height. Seen by these surgeons soon after the accident, it 
was thought that the empty bicipital groove and the displaced tendon could be 
distinctly felt. At the end of two years the displacement continued, and at this 
period the patient had recovered nearly, but not wholly, the free use of his arm. 

1 Malgaigne, op. cit., Paris ed., 1855, vol. ii. p. 145. 

2 Gerster, New York Med. Journ., May, 1878, p. 487. 

3 "White, J. W., Surgeon to the Philadelphia Hospital, and Asst. Surgeon to the Univer- 
sity Hospital, Amer. Journ. Med. Sei., Jan. 1884. 



616 DISLOCATIONS OF HEiD OF RADIUS 



CHAP TEE VIII. 

DISLOCATIONS OF THE HEAD OF THE RADIUS 
(HUMEKO-EADIAL). 

I have recorded thirty-two examples of traumatic dislocation of the head of 
the radius as having been seen and examined by me ; of which twenty-seven 
were dislocated forward, or forward and outward, and only five backward ; or, 
rejecting those cases which were complicated with fracture, I have recorded 
fourteen cases of simple forward dislocation, and three of simple backward dis- 
location. My experience, therefore, does not correspond with the experience of 
Boyer, Velpeau, Vidal (de Cassis), Chelius, B. Cooper, Guthrie, Gibson, and 
some others, who declare that the dislocation backward is the more frequent of 
the two. Indeed, I ought to say of two of the examples of backward dislocation 
of the radius which have come under my notice, and which I have marked as 
simple, that they were ancient dislocations; and I am not entirely certain, there- 
fore, that they had not been originally complicated with a fracture, although at 
the time of rny examination they presented no such evidence. The third, which 
I believe to have been a genuine, simple backward dislocation, I will mention 
again in connection with this latter form of dislocation. I have seen one con- 
genital dislocation of the radius outward and forward, which I will describe 
more particularly in the chapter on Congenital Dislocations. 



§ 1. Dislocations of the Head of the Radius Forward. 

Causes. — A fall upon the elbow, the blow being received directly upon 
the posterior face of the head of the radius ; a fall upon the hand with 
the forearm extended and pronated; extreme pronation of the forearm ; 
or, according to Denuce, a blow upon the inside of the elbow, which is 
equivalent to a violent adduction of the forearm. 

. In children, and especially in those of a strumous habit, whose liga- 
ments are feeble, a subluxation forward, or even a complete dislocation, 
is occasionally produced by being lifted suddenly from the floor by the 
hand, or by an attempt to sustain the child when he is about to falL I 
have seen examples of this dislocation produced in this way. 

Batchelder, 1 Sylvester, 2 Goyrand, 3 and many other surgeons, have mentioned 
similar cases. In the case of Lydia Merton, four years old, the dislocation was 
caused by holding on by the hands after having fallen from a swing. Dr. 
Krackowizer related a case of complete dislocation forward, produced, as was 
supposed, in the act of turning the child in delivery. The arm was ecchymosed, 
and the dislocation was very distinct. 4 Leisrinck 5 saw an ancient dislocation 
forward in both arms, which were said to have been produced immediately after 
birth by violent torsion of the forearms, practised for the purpose of resuscitating 
the child. 

1 Batchelder, New York Journ. Med., May, 1856, p. 333. 

2 Sylvester, Amer. Journ. Med. Sei., vol. xxxi. p. 206, Jan. 1843. 

3 Goyrand, Ibid., vol. xxxii. p. 228, July, 1843. 

4 Krackowizer, New York Journ. Med., March, 1857, p. 262. 

5 Leisrinck, Deuts. Zeitschrift flir Chir., Dec. 12, 1873. 



DISLOCATIONS OF HEAD OF RADIUS FORWARD. 617 



Fig. 390. 



Pathological Anatomy. — The head of the radius is carried forward 
upon the humerus, and generally a little outward. In the case of Lydia 
Merton, already mentioned, the head of 
the radius, on the ninety-fourth day 
after the accident, was nearly in the 
centre of the humerus. The anterior 
and external lateral ligaments, with the 
annular, are in most cases more or less 
broken. Sometimes the anterior and 
external lateral are alone broken, the 
annular ligament being then sufficiently 
stretched to allow of the complete dis- 
location ; or the anterior and annular 
having given way, the external lateral 
may remain intact. 




In the specimens dissected by Danyau 1 
and Debruyn, 2 and also in the specimen 
deposited by Prestat 3 in the Dupuytren 
Museum, the annular ligament was not 
torn. In a specimen obtained by J. Hil- 
ton, 4 this ligament was only partially torn (Fig. 391), and the head of the radius 
had formed for itself a new socket on the front of the humerus. The same is 



Position of the head of the radius dis- 
located forward. The head of the radius 
rests on the anterior surface of the hume- 
rus, in the hollow above the external 
condyle, in front of the external con- 
dyloid ridge. (Pick.) 



Fig. 391. 




Dissection of a dislocation of head of radius forward. (Hilton.) 

the fact in a specimen represented by Kronlein, and contained in the Patho- 
logical Museum at Zurich, so that the movements of pronation and supination 
were completely restored. 

Symptoms. — The head of the radius can in general be distinctly felt in 
its new situation, rotating under the finger when the hand is pronated 
and supinated ; we may sometimes also recognize a depression corre- 
sponding to its natural situation, behind and below the little head of the 
humerus. 

[Erichsen says that the forearm is slightly flexed and in a mid-state between 
pronation and supination. (Fig. 392.) The hand and arm can be fully pronated, 
but cannot be supinated more than half. The whole of the outer side of the arm 
is deformed, being carried somewhat upward. (Fig. 393.)] 

The external border of the forearm is slightly shortened, and the arm 
inclines unnaturally outward. The tendon of the biceps is relaxed. The 



1 Poinsot. op. cit., p. 885. 2 Ibid. 

* Hilton, Bull. Gen. de Therap., t. xxxviii., 1850, p. 113. 



* Ibid. 



618 



DISLOCATIONS OF HEAD OF RADIUS, 



forearm is generally pronated, sometimes it is in a position midway 
between supination and pronation, but I have never seen it supinated. 



Fig. 392. 




Dislocation of the head of the radius forward; limit of flexion at elbow. (Erichsen.) 



Fig. 393. 




Dislocation of the head of the radius ; deformity of outer side of the arm when extended. 

(Erichsen.) 

I have particularly noticed this fact in my report made to the New York State 
Medical Society in 1855; and Denuce, who has also examined these cases care- 
fully, affirms that it is seldom supinated, notwithstanding the general statements 
of surgeons to the contrary. Wf 

The arm is usually a little flexed, and cannot be perfectly extended 
without causing pain. In some cases, especially when the dislocation has 
existed for a considerable length of time, the arm is capable of extreme 
and unnatural extension. This was the case with Lydia Merton. There 
is usually preternatural lateral motion ; but, except in old cases, the fore- 
arm cannot be flexed upon the arm beyond a right angle. 

Prognosis. — Denuce says : " The reduction is often impossible ; more 
frequently still, difficult to maintain." In proof of which he refers to 
the observations of Danyau and Robert. In the case of recent dislocation 
related by Robert, it was found impossible to maintain a reduction which 
he thought he had several times accomplished, and he believed that the 
difficulty consisted in a portion of the torn annular ligament having 
become entangled between the head of the radius and the condyle of the 
humerus. 1 Sir Astley Cooper was unable to accomplish the reduction in 
two recent cases ; and of the six cases which came under his immediate 
observation, only two were ever reduced. 

Malgaigne says that in a collection of twenty-five cases which he has made, 
the accident was unrecognized or neglected in six, and ineffectual efforts at 
reduction had been made in eleven ; so that only eight of the whole number 

1 Memoirs sur les Luxations du Coude, par Paul DenucS. Paris, 1854. 



DISLOCATIONS OF HEAD OF RADIUS FORWARD. 619 

were reduced. I have myself met with six of these simple dislocations which 
were not reduced, three of which, however, had not been recognized, and no 
attempt at reduction had ever been made; one had been treated by an empiric, 
Sweet, a " natural bone-setter," but without success ; one had been reduced, but 
it had become redislocated, and in the remaining example I was unable to 
reduce the dislocation on the seventh day. 



Fig. 394. 



Fig. 395. 





Head. of the radius forward. Anatomical 
relations. 



Head of the radius forward. External 
appearance of limb. 



The following are brief notes of four of these cases : 

In a man, aet. 23, the accident had occurred about one year before. The sur- 
geon did not recognize the dislocation, and no attempt had ever been made 
to replace the bones. The forearm was forcibly pronated and could not be 
supinated, but he could extend it completely, and flex it somewhat beyond a 
right angle. It was strong, and nearly as useful as before. H. H. B., set. 6; 
dislocation produced by a fall upon the elbow. The surgeon did not detect the 
nature of the injury. Eighteen years after, I found the head of the radius lying 
in front of the old socket, having formed a new socket, in which it moved 
freely. From the elbow to the hand the arm inclined outward, or to the radial 
side ; pronation and supination were perfect. He could flex the arm to an acute 
angle, but not so completely as the other. The arm was as strong as the other, 
but it was frequently hurt by lifting. A lad, get. 12, had a dislocation of the 
head of the radius forward. Thirty-nine years after he could not flex the fore- 
arm upon the arm beyond a right angle ; and when the attempt was made, the 
radius struck against the humerus. Complete supination was impossible. The 
arm was as strong as the other, except in raising a weight above his head. 
Occasionally he was annoyed with slight pains in this limb. U. L., set. 48, was 
thrown from a carriage, producing a dislocation of the right radius, and severely 
bruising the elbow-joint. He did not see a surgeon until six hours had elapsed. 



620 DISLOCATIONS OF HEAD OF RADIUS. 

The elbow was then much swollen, and exquisitely tender, and L. would not 
permit much, if any, examination to determine its condition. The doctor 
applied simple dressings, and the next day requested me to see him. The 
whole arm was then swollen and tender, and very little examination was admis- 
sible. The dressings were, therefore, not completely removed, but only laid 
open sufficiently to enable us to see the joint. We suspected a forward disloca- 
tion of the head of the radius, but could not positively determine the point — 
the patient not permitting any kind or degree of manipulation. We decided, 
therefore, to wait a few days until the inflammation had somewhat abated, and 
then, if the existence of a dislocation was ascertained, to attempt its reduction. 
On the seventh day the swelling had measurably subsided, and the diagnosis 
became satisfactory. We immediately placed him under the complete influence 
of chloroform, and made long-continued and violent efforts at reduction, but 
without success. Severe inflammation again followed these efforts, and L. would 
never consent to another trial. After four years I find the bone still out. He 
can flex the forearm upon the arm almost as far as he can the opposite limb ; 
he can carry it nearly to his mouth, the head of the radius sliding off upon the 
outer face of the humerus, and not resting plumply against it ; indeed, the radius 
seems to have been gradually pushed outward as well as forward. The hand is 
forcibly pronated, and cannot be supinated. The attempt to supine produces a 
click in the neighborhood of the head of the radius, as if it struck against a 
bone. The arm is as strong as the other, and not wasted. He has constantly 
pursued his occupation as a barber, after only a few weeks' confinement. 

If the dislocation is accompanied with a fracture of the ulna, unless 
the fracture is transverse or incomplete, reduction is not generally accom- 
plished. 

I have three times met with this accident thus complicated in children, in the 
treatment of which a much better result has been obtained. In the first ex- 
ample, a lad, aged nine years, had broken the ulna in its upper third and dislo- 
cated the radius forward. Both the fracture and dislocation were easily reduced, 
and in a few weeks the limb was sound and perfect, except that a slight fulness 
remained in front of the head of radius, and this continued for several years. 
In the second example, a lad of the same age, I reduced both the fracture and 
the dislocation by extending the arm from the wrist, while at the same moment 
pressure was made upon the head of the radius from before backward. A right- 
angled splint was applied and continued during a period of four weeks, being 
removed daily for the purpose of giving to the joint gentle, passive motion, etc. 
After this the arm was permitted to straighten gradually, and at the end of a 
month more the joint was moving freely, and with no degree of displacement at 
the point of fracture or dislocation. 

It is quite probable that in each of the above cases the separation was not 
complete, although crepitus was distinct, and the displacement of the broken ends 
was very marked. In the following case the fracture was certainly incomplete : 
E. C, set. 4, had a fracture of the ulna, two inches below its upper end, the 
fragments being inclined backward, while the radius was dislocated forward. 
Both bones were easily replaced, and the functions of the arm were soon com- 
pletely restored. 

Where the restoration has been promptly effected and maintained 
steadily, the motions of the joint are soon restored ; but in one case the 
head of the radius has been found to play very freely and loosely after 
the lapse of two years, and in others it has remained slightly prominent 
in front, as if it was a little in advance of its socket. 

Treatment. — Extension and counter-extension should be made in the 
direction in which we already find the limb, namely, with the forearm 
slightly bent upon the arm, while at the same moment the surgeon should 



DISLOCATIONS OF HEAD OF KADIUS BACKWARD. 621 

seize the elbow with his hands, and press the head of the radius back 
with his two thumbs. 

Other methods will often succeed ; but by this we relax the biceps, and put 
the parts in the best position to accomplish the reduction easily and promptly. 
Sir Astley directed to supine the forearm while the extension was being made 
from the hand, but Denuce prefers that the forearm should be in a position of 
pronation. 

After the reduction is effected it is never safe to straighten the arm 
completely at once, nor indeed for some weeks ; not until the ligaments 
have been sufficiently restored to resist the action of the biceps. The 
arm must, therefore, be flexed and placed in a sling, or, if the radius is 
disposed to become redislocated, a right-angled splint ought to be placed 
upon the back of the arm and forearm, and, by the aid of a compress 
and roller, an attempt should be made to retain it in place. Nor will it 
be found safe at any period to compel the arm by force to resume the 
straight position, since this bone, when it has once been dislocated, will 
for a long time be liable to dislocation. 

A boy, aged about four years, had a forward dislocation of the head of the 
radius. The dislocation had existed several months. The father's purpose in 
bringing the child to me was to ascertain whether he could not claim damages 
for malpractice. The account which he gave was as follows: The surgeon 
called it a dislocation forward, and pretended to reduce it. A right-angled 
splint was applied with a roller. At the end of three weeks the father removed 
the splint, but did not discover anything out of place. Finding, however, 
that the elbow was stiff, he took measures to straighten it forcibly. In a few 
days he discovered the head of the bone out of place, and so it has remained 
ever since. I explained to him that there was much reason to suppose that the 
surgeon had properly reduced the dislocation, and that he had himself repro- 
duced the accident, by straightening the arm, through the action of the biceps 
upon the upper end of the radius. The father declined any further surgical 
interference, and no prosecution has followed. 

The late Dr. Batchelder, of New York, has described a method of reduction 
suggested to him first by Dr. Goodhue, of Chester, Vt., and which he had him- 
self found more successful than any other method ; indeed, he says it never fails, 
yet he does not inform us in precisely how many cases he had made the trial. 
The plan suggested consists essentially in first making extension from the hand, 
and pressing at the same time downward and backward upon the head of the 
radius until it has descended to a level with the articulating surface of the 
humerus. As soon as this is accomplished, the forearm is to be suddenly flexed 
upon the arm in such a direction as that the hand shall pass outside of the 
shoulder ; at the same moment, also, the pressure must be continued vigorously 
upon the head of the radius. 1 



§ 2. Dislocations of the Head of the Radius Backward. 

Denuce has collected fourteen examples of this dislocation ; but Mal- 
gaigne, who rejects a portion of the cases, and adds one or two more, 
admits only twelve. 

In addition to those mentioned by these two writers, I have found recorded, 
or incidentally noticed, one by May, 2 one by Bransby Cooper, 3 one by Lawrence, 4 

1 Goodhue, New York Journ. of Med., May, 1856, p. 333. 

2 May, Sir Astley Cooper on Dislocations, etc., by B. Cooper, op. cit., p. 403. 

3 B. Cooper, Ibid., p. 404. 4 Lawrence, Pirrie's System of Surgery, p. 259. 



622 DISLOCATIONS OF HEAD OF RADIUS 

one by Liston, 1 two by Case, 2 two by Gibson, 3 one by Parker, 4 three by Markoe, 5 
two by Conner, 6 one by Mack, 7 and one by Eivington, 8 and to these my own 
observations have added five more, in all thirty-three supposed examples. 

Of the examples brought under my own notice I have already affirmed 
that two of them were accompanied with fracture, and I am not certain 
but that all except one were. Markoe, of New York, who reported three 
cases, found in each a fracture of the internal condyle of the humerus, 
and, after an examination of a number of the reported examples, he does 
not find any evidence that this dislocation ever occurs as a simple uncom- 
plicated accident. It seems quite certain, however, that the backward 
dislocation does so occur, yet it is no doubt exceedingly rare. 

The following case, brought to my notice by Dr. Berry, of Fall River, Mass., 
must be accepted as a genuine example, inasmuch as the mode of its occurrence 
seems to preclude a fracture: "Frederick Kuger, of New York, was seen by 
me when he was fifteen years old, having a dislocation of the head of the left 
radius backward, which the mother stated was caused by a convulsion when he 
was one year old. The button-like head of the radius could be distinctly felt, 
and there was no evidence of any other injury." 9 

Dr. N. K. Freeman, of this city, reports one of the few cases which seems to 
admit of but very little doubt. A gentleman, set. 37, by jumping from the rail- 
road cars received a backward dislocation of the head of the radius of the right 
arm. "The symptoms," says Dr. F., "were marked; the hand and forearm 
were prone, and the attempt to place them in the supine position caused great 
pain ; while the head of the radius formed a considerable projection posterior to 
the external condyle of the humerus, where the cavity on its extremity could 
be distinctly felt. Assisted by Dr. Walsh, who firmly grasped the humerus, I 
was enabled to reduce it by extending the forearm and flexing it upon the arm, 
at the same time pronating the hand, and pressing forward the head of the radius 
with my thumb. After the reduction was effected, I requested Dr. Walsh to 
examine it; when upon slight extension being made upon the forearm, with 
supination of the hand, the bone was again dislocated. I immediately reduced 
it in the same manner as before, and directed the patient to keep the forearm 
flexed and the hand prone, and, laying it upon a pillow, apply cold water. He 
complained of severe pain for two days, which gradually subsided, and on the 
fourth day he was able to move and extend the forearm." 

Causes. — -The usual causes are, a direct blow upon the front and upper 
part of the radius; a fall upon the elbow, or upon the hand; a violent 
effort to supinate the forearm while it is grasped and held firmly in a 
state of pronation ; and probably it is sometimes occasioned by a twisting 
of the arm in machinery, etc. 

[The precise action of the forces by which this dislocation is produced is not 
yet determined. Experimentally it has been found by Barros 10 that it may be 
produced in children by a direct blow upon the head of the bone from the front 
and by violent extension of the hand, pronated, with sudden flexion of the forearm. 
This force caused a rupture of the posterior part of the lateral ligament, which 

1 Liston, Practical Surgery, p. 88. 

2 Case, Amer. Journ. of Med. Sci., vol. vi. p. 254, from 11th No. of Provincial Med. 
Gazette. 

3 Gibson, Institutes and Practice of Surgery, 6th ed., vol. i. p. 379. 
' Parker, New York Journ. of Med., March, 1852, p. 188. 

» Markoe, Ibid., May, 1855, p. 382. 

e P. S. Conner, The Clinic, Aug. 15, 1874. 

t G. J. Mack, The Med. Eecord, Dec. 2, 1876, p. 779. 

8 Eivington, Lond. Hosp., Lancet, Dec. 27, 1879. 

9 Berry, New York Med. Gaz., vol. vii. No. 6, Feb. 7, 1880. 
i° Barros, Centralblatt fur Chirurgie, 1886. 



DISLOCATIONS OF HEAD OF RADIUS BACKWARD. 623 

seemed to be necessary to the dislocation. Streubel 1 employed hyperextension of 
the forearm while supinated, with forcible flexion upward and to the radial side. 
Cameron reports a case in which a man had a dislocation caused by the pressure 
of a cart upon the hand while the elbow rested against a wall. These various 
conditions may all be explained, probably, by the supposition that the lateral 
ligament is first torn, and then, by a twisting force, with flexion, the partially- 
liberated head is thrown backward.] 

Pathological Anatomy. — In the case reported by Sir Astley Cooper, 
in which a dissection was made, " the coronary ligament was found to be 
torn through at its forepart, and the oblique had given way. The cap- 
sular ligament was partially torn, and the head would have receded much 



Fig. 396. 



Fig. 39^ 





Dislocation of the head of the radius 
backward ; front view. 



Dislocation of the head of radius back- 
ward; radial side. 



more, had it not been supported by the fascia w T hich extends over the 
muscles of the forearm.'' The head of the radius was thrown behind 
the external condyle of the humerus, and rather to the outer side. This 
was an ancient dislocation found in the dissecting-room of St. Thomas's 
Hospital, and the accompanying drawing is copied from the sketch made 
at the time. 



Two specimens have been presented to the Anatomical Society of Paris of 
complete ancient dislocation backward, one by Guion 2 and one by Petit. 3 In 
Guion's specimen the man was at the time of his death about fifty years old, and 
the ligamentous apparatus of the joint seemed to be untorn ; a fact which might 
easily be explained by supposing that in the great lapse of time since the acci- 
dent it may have been reconstructed. The same was the fact in Petit's case, and 
probably admits of the same explanation. The accident had happened in child- 
hood, and death occurred when the patient was twenty- eight years old. Osteo- 
phytes existed to a considerable extent, and the trochlear surface of the humerus 
was notably deformed. 

1 Streubel, Prag. Vierteljabrschrift, 1850. 

2 Guion, Bull. Soc. Anat. de Paris, 1859, p. 350. 

3 Petit, Ibid., 1874, p. 904. 



624 



DISLOCATIONS OF HEAD OF RADIUS. 



Fig. 398. 



If the dislocation is not complete, as occasionally happens with children, 
the annular ligament may not be torn. In such examples the projection 
of the head of the radius may not be easily recognized, but the motions 
of flexion and rotation would be impaired. The reduction is sometimes 
effected spontaneously, or with slight manipulation. In some cases, how- 
ever, the reduction is difficult or impossible, owing perhaps to the slipping 
of the annular ligament over the head of the bone, or to some other 
inter-articular complication. 

Symptoms. — The head of the bone is felt rotating behind the outer 
condyle, and a depression exists corresponding to its original position. 
The forearm is slightly flexed and prone; and the 
whole arm is deflected outward from the elbow down- 
ward; flexion and extension are difficult, while supina- 
tion is impossible. 

Treatment. — Most surgeons have taught that while 
extension and counterrextension are being made, the 
forearm should be forcibly supinated, and that at the 
same time the head of the radius must be strongly 
pushed forward. Martin recommends to extend forci- 
bly, and then suddenly flex the arm ; in a manner very 
similar to the plan recommended by Batchelder in dis- 
locations forward. In Dr. Freeman's case, just quoted, 
the reduction w T as effected while the forearm was pro- 
nated, and supination seemed to throw it again out of 
place. Dr. Middleditch, in the case reported by Mack, 
succeeded in his first effort by making extension with 
the arm flexed to a right angle, while pressure was 
made upon the head of the radius. According to Mar- 
koe, where the accident is complicated with a fracture 
of the inner condyle, when the reduction is accomplished 
the arm should be placed in a position about ten degrees 
less than a right angle, and supported by a splint with 




Dislocation of the 
head of the radius 
backward. 



bandages, etc. 



If the dislocation is simple, however, I can see no objection to its being nearly 
or quite extended, since in this dislocation the action of the biceps would only 
tend to retain the head of the radius in place. 

§ 3. Dislocations of the Head of the Radius Outward. 



Denuce has' collected four examples of this accident, unaccompanied 
with a fracture, and he proceeds to speak of it as a distinct form of dis- 
location. In two of the examples, however, mentioned by him, it was 
consecutive upon a forward dislocation, and I have several times seen the 
head of the radius very much inclined outward in what are properly 
termed forward dislocations. For these reasons it is not very plain to 
me that we ought to consider this as a distinct form of primary disloca- 
tion ; but it would seem that we ought rather to regard it as a consecu- 
tive dislocation, or at least as only a modification of the forward or 
backward dislocation. Indeed, I think the radius never will be found 



Fig. 399. 



DISLOCATIONS OF HEAD OF RADIUS OUTWARD. 625 

thrown directly outward, but always in a direction inclining forward or 
backward. 

Parker, of this city, mentions a case which came under his notice, in a child 
four years old, who, six weeks before, had fallen down stairs "backwardly, with 
the right arm twisted behind the back, in such a position that the whole weight 
of her body came upon her arm." No attempt was ever made to reduce the 
bone, and the head of the radius continued to project externally. By pressure 
it was easily reduced, but became imme- 
diately displaced when the forearm was 
either flexed or extended. The motions of 
the joint were completely restored. Dr. 
Parker recommended no treatment. 1 

[The following is a summary of the more 
important facts in cases not mentioned in 
the text : In Thomassen's case " the head of 
the radius projected at the top of the convex 
border of the forearm, pressing outward the 
mass of the supinator and radial muscles 
which cover it;" in Chedieu's case "the 
head of the radius projected at the outer 
and upper part of the forearm, rising higher 
than the external condyle." Nelaton illus- 
trated his case (Fig. 402) ; it occurred in 
childhood and had existed twenty years. 
Gerdy found in his case the head of the 
radius projecting considerably outside of the 
epicondyle. Yon Pitha's patient was a girl, 
set. 9 ; a servant stepped with her heel upon 
the elbow while the arm lay on the floor ex- 
tended and supinated ; the head of the radius 
lay on the outer surface of the condyle. 
Broca's case was a girl, aet. 11 ; the head of 
the radius lay external to the condyle very 
superficial and movable. Wagner reports 
three cases, as follows: 1. A boy, set. 18, 
while pushing a wagon with the forearm 
pronated and flexed was struck on the 
elbow ; one year later flexion, extension, 
and rotation were almost entirely lost ; ex- 
cision of the head restored in some degree 
the usefulness of the joint. 2. Man, aet. 26, 
reduction effected with diffi- 




Nelaton's case of dislocation of the 
head of the radius outward. 



same cause, 

culty ; five months after, joint so firm that excision was performed ; no improve- 
ment. 3. Man, who was injured, when six years old, by a fall; movements of 
joint normal ; head of radius outside of the external condyle. Tobken reports 
two cases, with fracture of the head, treated by excision. Bartels reports a double 
displacement in a man, due to the practice, when a boy, of pushing a loaded cart 
before him.] 

Poinsot, in a note to the French edition of this treatise, has seen fit to recog- 
nize these partial dislocations forward or backward, when occasioned in child- 
hood by lifting the body by the arms, as a distinct variety of radial dislocations, 
or, as he has designated them, "dislocations of the head of the radius downward 
(by elongation)." The grounds upon which he bases these distinctions are 
ingenious and specious, but they do not seem to me satisfactory. 

1 Parker. New York Jouru. Med., March, 1852, p. 189. 



40 



626 DISLOCATION OF HEAD OF RADIUS DOWNWARD. 



§ 4. Dislocation of the Head of the Radius Downward (by Elongation). 

[There is a form of injury at the elbow-joint frequently noticed in 
children. It more often occurs when the child is lifted by the hand and 
has been variously explained by writers. The following very full discus- 
sion of the subject under the above title, by Dr. Poinsot, the editor of the 
French edition of this work, embraces the more important facts relating 
to this accident :] 

["This displacement, peculiar to childhood, and which results from violent 
traction having been made upon the forearm, has been described by Malgaigne, 
Denuce, and most surgical authors, when speaking of the dislocations forward 
and backward, as being a partial variety of one of those. For several reasons, 
however, it has seemed to us preferable to devote to it a separate paragraph ; if, 
in many of those dislocations of infancy, the head of the radius is found either 
forward or, much more rarely, backward, it is nevertheless true, as we shall see 
presently, that in all cases the mechanism of the primitive displacement is the 
same ; the cause by which the bone is kept in its abnormal situation is identical ; 
in all cases the traumatism is due to a violence of the same order. The analogy 
is as great regarding the symptoms and the prognosis. So alike between them, 
whatever the direction of the displacement may be, these dislocations in chil- 
dren differ absolutely from the partial dislocations in the adult ; the former are 
entirely of a benign character, and their reduction is often spontaneous ; the 
latter, on the contrary, are apt to be irreducible, or they always necessitate cer- 
tain efforts for reduction. In the first case, after the displacement is once 
reduced, the child is apt to use his arm as well as before, and no precaution is 
needed to prevent the dislocation from being reproduced ; in the second case, it 
is often very difficult to keep the parts in place, and the patient is always obliged 
to wear an apparatus for a certain length of time. Therefore, the authors men- 
tioned above have been obliged to divide partial dislocations into dislocations 
in adults and dislocations in children, and, again, when coming to dislocations 
backward, such as are observed in the latter, in order to avoid repetition, they 
had to refer the reader back to what they had said when speaking of analogous 
displacements forward. Those reasons seem to us amply sufficient to justify the 
classification which we have adopted. 

" Causes and Mechanism. — The dislocation downward has been most fre- 
quently observed in children two or three years of age ; after six years it becomes 
exceptional. Bourguet, however, met with an example of it in a child thirteen 
and a half years old. 1 Again, Duges has met with it in a newly-born infant, 2 
and Malgaigne in children still nursing. At all events, certain subjects seem 
predisposed to this accident ; thus, in two cases, Perrin has seen the displace- 
ment take place in both forearms simultaneously or successively with a persistent 
tendency to its recurrence. 3 The immediate cause, noted in the immense 
majority of cases, is a traction, with or without tortion, made upon the hand or 
forearm, such as in the act of lifting a child to make him pass over an obstacle 
or to prevent him from falling or in trying to force his hand through a sleeve 
that is too narrow. Eendu 4 and Descamps 5 have observed the dislocation down- 
ward in children who had been made to jump, as an amusement, while being 
held, by the hands. 

"The mechanism of these dislocations in children has been variously under- 
stood by authors. Fournier, and, with him, Duverney, Jr., had admitted an 
elongation of the radius by stretching of the ligaments; but, being devoid of 
any anatomical proof, this theory was forgotten before long. The articular 

1 Bourguet, d'Aix, Eevue Medico-Chirurgieale, 1854, t. xv. p. 288. 

2 Duges, Journal Hebdomadal re de Medecine, 1831, t. iv. p. ]97'. 

3 Perrin, Journal de Chirurgie de Malgaigne, t. i. p. 136 ; Revue Medico-Chirurgieale, 
t. v. p. 146. 

4 Eendu, Gazette Medicale de Paris, 1841, p. 301. 

5 Descamps, Luxation Incomplete des Enfants, Th. de Paris, 1876. 



DISLOCATION OF HEAD OF RADIUS DOWNWARD. 627 

displacement being most often very difficult to establish, it was preferred to 
deny its existence. Gardner 1 and Rendu maintained that the characteristic 
difficulty in movements of the forearm was due to a hooking of the bicipital 
tuberosity by the external border of the ulna, and Bourguet, in addition to that, 
supposes that there are muscular fibres of the supinator brevis interposed be- 
tween the two bones. The editor of the Medico-chirurgical Review has thought 
of an epiphyseal separation. 2 Goyrand, observing that the interosseous space 
was too large to allow the hooking of the tuberosity of the radius, admitted at 
first that the head of that bone was displaced forward by the biceps, and was 
fixed in that position, against the inferior extremity of the humerus, by the con- 
traction of the other muscles; but, later on, he abandoned this first opinion and 
denied that the radius had any participation in the traumatism in question, 
seeing in the latter only a subluxation of the inter-articular cartilage of the 
wrist upon the inferior extremity of the ulna. 3 Perrin finally came back to the 
idea, already enunciated by Duverney, of a displacement downward, and, in 
order to explain its persistency, he supposed that the edge of the radial cup was 
pressing against the condyle. Each one of those theories was liable to palpable 
objections ; we have seen Goyrand criticise very justly the theory of hooking ; 
the one in which muscular contraction intervenes in order to pull and fix the 
radius forward implies a flexion of the forearm, and especially a muscular 
rigidity which are far from being constant. The localization of lesions at the 
elbow cannot be disputed ; as to the epiphyseal separation, it has yet to be con- 
firmed, not only anatomically, but also clinically. Finally, the mode of dis- 
placement admitted by Perrin would necessarily require a lowering of the radius 
to the extent of eight or nine millimetres, which would consequently be very 
difficult to discover, since it is often impossible to establish the least change of 
relations between the bones. 

"Thus stood the question when M. Pingaud, resuming some experiments 
formerly made by Streubel, threw an entirely new light upon it. Streubel, 
while regarding the partial displacement of the radius forward as the character- 
istic anatomo-pathological feature of the dislocation of childhood, and while 
considering the movement of torsion of the forearm as the principal factor in 
the production of this accident, had noticed that the fixedness of the bone in its 
abnormal position was due to the interposition of a portion of the capsule and 
of the annular ligament. 4 The results of M. Pingaud's experiments were also 
to demonstrate beyond doubt interposition of the capsule, while establishing, 
contrary to Streubel, that the displacement of the radius downward, its elonga- 
tion, to use Duverney's expression, constitute the primitive displacement. 'If,' 
says M. Pingaud, ' we examine what is going on toward the humero-radial 
articulation, when the wrist and the hand of the little cadaver are carried into 
a state of forced adduction, so as to pull the radius from below, a noticeable 
separation is seen to take place over the articular interline, and the atmospheric 
pressure drives and depresses the integuments toward the interior of the articu- 
lation. So soon as the traction is abandoned, the radius reascends and resumes 
its place. In this manner the radius may be made to move back and forth in 
a parallel direction to the ulna and without any great effort. 

" ' If the traction is suddenly carried somewhat further, a slight click is heard, 
and then the following facts are witnessed : 1. The moment traction is aban- 
doned, the radius does not go up so easily nor so high as it did previously, and 
a line of depression, perfectly appreciable to the eye and to the finger, is seen to 
separate its head from the articular condyle. 2. The head, however, is in its 
place under the condyle, inasmuch as it does not project abnormally either 'for- 
ward, backward, or outward. 3. The movements of rotation of the hand, especi- 
ally that of supination, are not so free as before ; in a word, there is somewhere 
a slight but perfectly appreciable obstacle to the regular performance of those 
movements. 4. Finally, these movements of rotation cause a slight displace- 
ment of the head of the radius in front of the condyle when pronation is slightly 
forced. 

1 Gardner, Gaz. Med. de Paris, Oct, 21, 1837, p. 664. 

2 Medico-chirurgical Review, 1839. 

3 Goyrand, Armales de la Chirurgie, 1842, t, v. p. 129. 

4 Streubel, Prager Vierteljahrsschrift, 1850, Bd. i. u. ii. 



628 DISLOCATION OF HEAD OF RADIUS DOWNWARD. 

"' If the parts be dissected, they are found in the following condition : No 
tearing of muscle or ligament can be perceived at the humero-radial articula- 
tion, but there is seen a small segment of the radial cup completely uncovered 
by the annular ligament, which has moved upward only in front. It is evident 
that the narrow fibrous ring which, in a physiological condition, terminates the 
annular ligament below and surrounds the neck of the radius, has, owing to its 
elasticity during youth, been gradually stretched by the lowering of the head of 
the bone, and that it has gradually slipped above it, at the point only where it 
is not adherent to the deep surface of the muscles covering it, and where the 
bony cylinder representing the head of the radius offers so little prominence in 
the child as to be reduced, so to speak, to a simple border.' 

" If, then, the forearm be placed in a state of pronation, a larger portion of 
the radial cup is seen to emerge from below the annular ligament, and to such 
an extent that, at the extreme, it might be entirely disengaged from under it, 
and the head of the radius might be entirely dislocated forward ; but the latter 
displacement is always secondary, and the first stage of the accident now under 
our consideration consists in the displacement of the head downward. 1 Such is, 
therefore, the mechanism of the subluxation in all the rather numerous cases 
where the head is found slightly displaced forward ; but it could not be applied 
to the cases where an opposite displacement is observed — viz. : that of the head 
backward. M. Pingaud has remained almost silent on this latter point, but an 
experiment of Streubel will help us to solve the difficulty ; indeed, Streubel 
remarked that, if a sudden movement of extension and supination be applied to 
the forearm of a young subject, the head of the radius is plainly felt being dis- 
placed backward. If the same experiment be repeated after having removed 
the skin and the muscles covering the articulation, the posterior portion of the 
capsule and of the annular ligament may be seen to be highly distended, while 
at the same time a depression of more or. less depth is produced at the anterior 
portion, the atmospheric pressure determining at that point the interposition of 
the corresponding portion of the capsule. Here, again, a primitive displacement 
downward is necessary to allow the separation of the bones and the interposition 
of the ligaments, the movement of supination intervening only to determine 
the direction of the secondary antero-posterior displacement. 

u To sum up regarding the partial dislocation in children: 1. The primitive 
displacement, resulting always from a traction applied in the direction of the 
axis of the radius, consists essentially in a lowering of that bone which allows 
the interposition of the capsule and of the annular ligament. 2. The move- 
ment of torsion of the forearm has influence only upon the secondary displace- 
ment,' in order to determine its direction antero-posteriorly. 

" Symptoms.— At the time of the accident, the person holding the child by 
the hand can generalty perceive a cracking in the joint. At the same time the 
child experiences in the elbow a very sharp pain, which he manifests by his 
cries, and the limb is seen to be powerless ; it falls inert, generally flexed one- 
quarter, and in a position midway between pronation and half-pronation. In a 
few exceptional cases, however, almost complete extension and supination of 
the forearm have been met with. The deformity is ordinarily very slight; 
Bourguet had called attention to an increase of the antero-posterior diameter of 
the elbow which has not been confirmed by the other observers. Is is pretty 
rare, notwithstanding Malgaigne's statement, to see a prominence of the head of 
the radius in front; the prominence behind is scarcely ever observed. The 
symptoms of the partial dislocation in children are, as may be seen, pretty 
vague ; those that may be considered as characteristic are the inertia of the 
limb and the impossibility to give the forearm the necessary movement of torsion 
in order to bring it back in the opposite position to that in which it is found 
(movement of supination if, as is generally the case, the forearm is found in 
pronation, and vice versa). 

« Prognosis. — Left to itself, that dislocation gets well almost always, and 
often there is no time even to consult the surgeon. My brother, then two years 
and a half old, experienced an accident of this kind ; he had been made to jump 

1 Pingaud, art. " Coude," in Diet. Encyclopedique des Sci. Med., Ire serie, t. xxi. 
p. 581. 



DISLOCATIONS OF THE UPPER END OF THE ULNA. 629 

over a gutter by being lifted by the hand. Before the family physician could 
arrive, the displacement was reduced by means of a few frictions applied at the 
bend of the elbow, and, probably, also of a few attempts at extension of the 
forearm ; the symptoms disappearing at once. Nevertheless, that spontaneous 
reduction may be tardy, and it is better to act without delay. 

" Treatment. — The different modes of reduction indicated in the case of com- 
plete dislocations are applicable in this instance. Generally, when the forearm 
is in a state of pronation, it is sufficient, during extension, to bring back by 
force the limb into supination, and then to flex it suddenly. If the forearm is 
in a state of supination, it will be necessary, after having exaggerated the exten- 
sion, to put the limb in pronation, but without flexing it. In case some dis- 
placement of the radius should be noticed, it would be well to add to these 
manoeuvres a certain amount of pressure upon the head of the radius in the 
direction of the condyle of the humerus.''] 



CHAPTEE IX. 

DISLOCATIONS OF THE UPPER END OF THE ULNA 
(HUMERO-ULNAR). 

§ 1. Dislocations Backward. 

This accident, the existence of which, as a simple dislocation, is 
placed beyond doubt, has nevertheless been described so variously, and 
often indefinitely, that it is impossible to declare its history, except in a 
few points, with any degree of accuracy. No doubt, many of the cases 
which have been reported were examples only of a subluxation of both 
radius and ulna backward. In other cases, the radius or the external 
condyle of the humerus being broken, the ulna has been actually dis- 
placed, not only backward, but upward : indeed, it is very certain that 
without either dislocation of the radius or a fracture with displacement 
of the external condyle of the humerus or a fracture or bending of the 
radius, an upward displacement of the ulna, to the degree represented 
by the reporters of these cases, could never have occurred. 

The example mentioned by Sir Astley Cooper, and of which a dissection was 
made, is plainly a case of subluxation of both bones ; or if the dislocation of the 
ulna may be regarded as having been complete, the head of the radius was also 
displaced more or less upward from its original socket ; a new socket, Sir Astley 
himself informs us, having been formed for its reception, upon the external con- 
dyle. But this is the only example the actual condition of which has been 
proven by an autopsy. 

Nevertheless, it seems certain that a simple dislocation or subluxation 
of the ulna backward may occur without either of the above-mentioned 
complications, and that, to the extent of a few lines, it may be made to 
pass upward upon the back of the humerus, by the falling of the forearm 
to the ulnar side ; in which case the character of the accident would 
probably be recognized by the projection of the olecranon process, while 
the head of the radius might be felt moving in its socket : by the partial 



630 DISLOCATIONS OF THE UPPER END OF THE ULNA. 

flexion and complete pronation of the forearm, and by the general immo- 
bility of the joint. 

In a case reported by Dr. Waterman, caused by a fall on the hand, the arm 
was at a right angle, and pronated. 1 

[Three forms of dislocation are now recognized, though they are but varieties 
depending upon the kind and amount of violence : 1. The coronoid process may 
merely have passed backward over the trochlea; 2. Or it may have gone farther 
and lodged in the olecranon fossa ; 3. Or the olecranon may be thrown behind 
the radius. The diagnosis of these varieties depends upon an examination and 
correct appreciation as to the position of the head of the radius, which is not 
disturbed, and of the olecranon process, which projects posteriorly more or less, 
or laterally, according to the variety.] 

Treatment. — Its reduction ought to be accomplished easily by the 
same measures which have been found successful in reducing a dis- 
location of both bones backward; but in Waterman's case this method 
failed, and the reduction was promptly effected by bending the forearm 
forcibly back. 

Pirrie says that in a case occurring in the practice of Mr. Gosset, in which 
the coronoid process rested on the internal condyle, and the pain on bending 

Fig. 400. 




Dislocation of the upper end of the ulna backward. 

the arm was insupportable, owing, it was supposed, to the pressure of the coro- 
noid process against the ulnar nerve, "reduction was accomplished by extension 
and counter-extension applied by two persons pulling in opposite directions, 
and by the pressure of the olecranon process downward and outward, while the 
forearm was suddenly flexed." 2 Eosner 3 employed with success the same pro- 
cedure in a case of incomplete dislocation, which had existed eight months in a 
boy, set. 18. 

[Scott, of Bath, reports 4 a case of dislocation of the ulna backward and of the 
radius forward, in a man set. 46. The patient was thrown over the head of a 
horse while riding rapidly and struck on his hands., The arm was almost straight, 
the prominences of the external and internal condyles had disappeared ; the 
olecranon was about one and a half inches above the condyles; there was a 
sulcus on each side of the triceps; the head of the radius could not be felt 
behind the elbow. The dislocated ulna Avas easily reduced by the knee in the 
bend of the elbow, but the forearm could not be fully flexed. The head of the 
radius could not be readily felt resting on the anterior surface of the external 
condyle. With the knee again in the bend of the elbow pressure was made at 
the same time that flexion was gradually induced and pressure was made upon 
the head of the radius. Eeduction of both bones was thus effected.] 

1 Waterman, Boston Med. and Surg. Journ., vol. iv., new series. 
3 Gosset, Pirrie's Surg., Amer. ed.,p, 259. 

Rosner. Wiener Allgem. med. Zeitung, 1875, No. 32. 

British Medical Journal, 1886. 



DISLOCATIONS OF RADIUS AND ULNA. 631 



§ 2. Dislocations Inward. 

Dr. George Wright, of Toronto, 1 reported an example in a girl nine 
years old, of dislocation inward of the upper extremity of the ulna, the 
head of the radius remaining in place, caused, as was supposed, by a fall 
upon the elbow. 

Dr. Wright saw the patient the same day and recognized the dislocation, but 
as some of the surgeons who saw the case expressed a doubt as to the character 
of the accident, no attempt at reduction was made. Twenty-eight days after 
the accident "a careful examination was made by almost all the members of the 
staff, and accurate measurements between the bony prominences were taken, 
and all agreed that there was dislocation inward of the olecranon process upon 
the inner condyle of the humerus, the head of the radius remaining in its normal 
position. There was no pain or swelling ; all the motions of the arm were per- 
fect ; but the patient was unable to sustain any weight upon the arm in exten- 
sion by reason of the tendency to rotate inward, and the 'carrying power' was 
lost. I attempted reduction under anaesthetics, but after an hour and a half's 
effort by myself and all the gentlemen present, and by every means suggested 
by the best authorities, we failed to reduce the dislocation. The arm was put 
in an elevated easy position, with patient in bed, cold water applied, and not a 
single bad symptom followed this somewhat violent manipulation. The friends 
refused to allow any further attempts at reduction." 

In explanation of the peculiarity of the displacement, Dr. Wright states that 
there existed a congenital laxity of the ligaments of all the joints, and that 
"when the child was two years of age she received an injury to this same elbow 
which caused the separation of this epiphysis, the external condyle being broken 
off, and it may be that this accident left a condition in the joint which favored 
the possibility of the inward displacement of the upper extremity of the ulna 
without carrying the radius with it." 



CHAPTEE X. 



DISLOCATIONS OF THE KADIUS AND ULNA (FOREABM) AT 
THE ELBOW-JOINT. 

The radius and ulna may be dislocated at the elbow-joint backward; 
laterally, that is, either inward or outward ; and forward. They may 
also be dislocated in opposite directions. 

§ 1. Dislocations of the Radius and Ulna Backward. 

My records of private and hospital practice supply seventy-two cases ; the 
youngest being four years old, and the oldest sixty-one. Twenty-nine of this 
number occurred in children under fourteen years of age. 

Causes. — Generally the dislocation has been produced by a fall upon 
the palm of the hand, as, when in running, a person has fallen forward 
with the forearm extended in front of the body, or he may have fallen 

1 Wright, Canadian Journ. Med. Sci., Feb. 1882. 



632 



DISLOCATIONS OF RADIUS AND ULNA. 



from a height ; once I have known it produced by a blow received upon 
the back and lower part of the humerus ; and in several instances the 
patients have declared that they had fallen upon the elbow ; it is pro- 
duced occasionally by twisting the forearm violently, as when the limb 
has been caught and wrenched about by machinery, by a blow upon the 
front and upper part of the forearm, and by forced flexion. 

Pathological Anatomy. — The radius and ulna are not only carried 
backward behind the articulating surface of the humerus, but they are 
also, through the action of the triceps, almost always drawn more or less 
upward, so that often the coronoid process of the ulna rests in the ole- 
cranon fossa. In some cases it has been known to mount even higher, 
while in others it is arrested short of this point. The radius still retain- 
ing its relative position to the ulna, lies upon the back of the humerus, 
or rather upon the posterior margin of its articulating surface. The 
anterior and two lateral ligaments are generally more or less completely 
torn asunder ; but the posterior ligament and the annular do not usually 
suffer disruption. The biceps muscle is drawn over the lower articulat- 



Fig. 401. 



Fig. 402. 





Position of bones in dislocation of the 
radius and ulna backward. 



Brachialis anticus and biceps muscles in dislo- 
cation of the radius and ulna backward. 



ing surface of the humerus, but is in a condition of only moderate tension > 
while the brachialis anticus is forcibly stretched, or even torn. (Fig. 402.) 

Malgaigne says the tendon of the biceps has once been found behind the 
humerus. The median nerve is also pressed upon in front by the humerus, and 
the ulnar is occasionally painfuly stretched over the projecting extremity of the 
ulna from behind. 



Symptoms. — -The arm is almost constantly found only slightly flexed, 
or forming an angle in front of about 120°. 

This fact is especially noticed in my records twenty-six times, and, if it had 
ever been found in any other position, it would certainly have been stated. 
Once, where the dislocation was accompanied with a fracture of the outer con- 
dyle of the humerus, the arm was at first straight, a position in which it is said 
to be found occasionally with children; and in the case of a patient admitted to 
Bellevue Hospital, the dislocation having existed thirty-one days, but unaccom- 



DISLOCATIONS OF RADIUS AND ULNA 



633 



parried with a fracture, I found the arm straight, and there existed also a pre- 
ternatural lateral mobility of the elbow-joint; but never, in any case of a recent 
dislocation, and but once in an old dislocation, have I found it flexed to a right 
angle ; yet I will not deny that such unusual phenomena are possible in recent 
dislocations; indeed, it is certain that they have occasionally been presented, 
but they must be regarded as only exceptional, and as by no means diagnostic 
of this accident. Sir Astley Cooper and Miller declare that in this dislocation 
the forearm is usually supinated ; Pirrie says " the hand is between pronation 
and supination, but more inclined to the latter." Desault thinks it is sometimes 
in supination and sometimes in pronation ; Denuce concludes that it will occupy 
that position, whatever it may be, in which the force of the blow has thrown it ; 
while by most surgical writers no allusion is made to the position of the forearm 
in reference to pronation or supination. I have found the forearm and hand 
almost constantly in a position of moderate but positive pronation, and I am 
compelled to regard it, therefore, as one of the usual signs of a backward dislo- 
cation of these bones. 

The limb can be neither flexed nor extended without force, and such 
motion is almost always accompanied with pain. It is, however, possible 
in most cases to give to the arm a slight lateral motion, such as does not 
belong to it in its natural condition. In front, and deep in the fold of 
the elbow, is felt the lower end of the humerus, forming a hard, broad, 
and somewhat irregular projection, over which the integuments and 
muscles are swollen, and tender to pressure. Behind, the head of the 
radius may be felt, wdien not much tumefaction exists, rotating or moving 
under the finger when the forearm is supinated or pronated ; while the 
olecranon process projects strongly backward and upward. If now we 
flex the arm slightly, this projection of the olecranon process will be 
sensibly increased , but if an attempt is made to straighten the arm, it 
will be diminished, the reverse of what we have seen to happen in cases 
of fracture of the lower end of the humerus (at the base of the condyles). 
This circumstance becomes, therefore, an important diagnostic mark 
between these two accidents. The relation of the olecranon process, 
also, to the condyle is changed, and the upper end of this process, instead 
of being a little below the internal condyle, as it w T ould be naturally 
when the arm is slightly flexed, is found generally carried upward toward 
the shoulder, from half an inph to one inch or more above the condyle. 
Measuring from the internal condyle to the styloid process of the ulna, 
the forearm is shortened ; the same result will be obtained also by 
measuring from the acromion process to either of the styloid processes ; 
while from the acromion process to the condyle, the length will be the 
same in both arms. 

The signs which have now been enumerated will be sufficient to enable 
us to make the diagnosis promptly in the great majority of cases, but, if 
considerable swelling has already taken place, the diagnosis may be ren- 
dered exceedingly difficult, if not impossible ; and in such cases we 
should confine the patient at once to his bed, and proceed to reduce the 
tumefaction by appropriate means as rapidly as possible, examining the 
limb carefully from day to day, in order that we may seize the earliest 
opportunity to ascertain its actual condition and to effect the reduction. 

In relation to the difficulty of diagnosis in certain examples of this accident, 
and under certain circumstances, Mr. Skey has made some very judicious re- 
marks : " Severe injuries of the elbow-joint, whether in the form of fracture, 



634 DISLOCATIONS OF RADIUS AND ULNA. 

dislocation, or a compound of the two, are frequently followed, at a short 
interval, by swelling of a formidable kind, in which it is impossible, but by the 
aid of a perfect intimacy with the anatomical structure of the joint, to detect 
the relations of one part with another ; but even under this difficulty, the two 
points in question are readily distinguishable. In such forms of swelling, the 
arm, including the length of six inches both above and below the joint, may be 
involved in the extravasation, and this swelling may distend the arm to a cir- 
cumference of one-third beyond its natural size. In such circumstances, in 
which it is impossible to determine with any certainty whether any, or what 
bones are broken, or whether or not dislocated, the difficulty of the case should 
at once be stated to the friends of the patient." 

Prognosis. — If the dislocation is recent, reduction is in general easily 
effected; but if considerable time has elapsed, the reduction is often 
accomplished with difficulty. As to the probability of its redislocation, 
I have already spoken when considering the subject of fractures of the 
coronoid process. Unless this process is broken, it is not likely to occur 
except where some violence has again been applied. It has happened 
to me, however, to find these bones unreduced in several instances. In 
some of these examples surgeons recognized the accident and supposed 
that they had accomplished reduction, while in others the dislocation was 
mistaken for a fracture. 

J. P., set. 25, had a dislocation backward of both bones at the elbow-joint. A 
surgeon recognized the dislocation, and by pulling the arm straight forward he 
supposed he had reduced it ; the patient also thought he felt the bones slip into 
place. No attempt was made subsequently to flex the arm, and it was imme- 
diately dressed with a straight splint laid along the palmar surface. On the 
sixth day it was found to be unreduced, and the surgeon again attempted to 
reduce it as before, and thought he had succeeded. The same splint was reap- 
plied. At about the end of six weeks three surgeons placed the patient under 
the complete influence of chloroform, and attempted the reduction. They first 
made extension for half an hour in a straight line, then five men seized upon 
the arm and forearm, bending it with great force to a right angle. It was now 
believed that the ulna was reduced, but not the radius. Four days after, the 
attempt was renewed. Three months after the accident the young man called 
upon me, and I found the arm nearly straight, with almost complete ankylosis 
at the elbow-joint. Both the radius and ulna were displaced backward, but not 
upward. The arm was of the same length with the other, and the relation of 
the condyles to the olecranon was so manifest, that the absence of the usual 
displacement upward was easily determined. I was unwilling to make any 
further attempts at reduction, not believing that I should succeed after so much 
time had elapsed, and after so many ineffectual attempts had been made by 
clever surgeons. 

In the following examples the dislocation was supposed to have been a frac- 
ture of the lower end of the humerus. A man, residing in Pittsfield, Mass., 
dislocated his left arm by falling from a horse. The surgeon who was called 
regarded it as a fracture at the base of the condyles, and treated it accordingly. 
Ten weeks after, the error was discovered and an attempt was made to reduce 
it, but without success. A second attempt was also made, with the same result. 
Eight months after the accident the bones were still unreduced. The forearm 
hung at a very obtuse angle with the arm, and there was very slight motion at 
the elbow-joint. I discouraged any further attempts at reduction. 

Mr. W., set. 43, fell from a load of hay, striking upon his left arm. A very 
intelligent young surgeon thought the humerus was broken just above the con- 
dyles. After eight weeks, the fact that it was a dislocation having become 
apparent, three surgeons of large experience attempted its reduction aided by 
pulleys and chloroform. The patient was also bled and nauseated with anti- 
mony. . The efforts were protracted through many hours, and frequently varied. 
A second attempt made by these same gentlemen, a few days after, was equally 



DISLOCATIONS OF RADIUS AND ULNA. 



635 



unsuccessful. On the ninth week, assisted by Prof. Moore, of Kochester, I re- 
newed the attempt at reduction. The patient was placed under the influence 
of chloroform, and during a great portion of the time occupied the pulleys were 
in use. The elbow was pulled upon, twisted, flexed, and extended, until there 
seemed to be neither adhesions, nor ligaments, nor capsule, to prevent the reduc- 
tion. TVc could move the joint in every direction, even laterally, as well as 
forward and backward. Still the bones would not return to their sockets. Sec- 
tion of the triceps seemed to be the only remaining expedient, but the injury 
already done to the joint was so great thai we did not deem it prudent to prose- 
cute the attempt any further. We had occupied two hours in the various pro- 
cedures. Violent inflammation supervened, but he was able to return home in 
about two weeks. Two years after, I learned that the arm still remained unre- 
duced, and nearly ankylosed ; the whole limb was also much atrophied and very 
weak. 



In at least eleven cases, according to my records, the accident has 
been overlooked by reputable surgeons ; the injury having been supposed 
to be either fracture or a mere con- 
tusion. In three or four instances the 
accident has been overlooked by the 
patient himself, or by some empiric, 
no surgeon having been called to see 
the case until after the lapse of several 
days or weeks. 

In general, when the reduction has 
been effected promptly, the patients 
have recovered the complete use of the 
elbow-joint within a few weeks ; but 
many exceptions have from time to 
time come under my notice. 

A lad 8 years old was brought to me, 
whose arm had been dislocated six months 
before, and the reduction of which had 
been accomplished easily and promptly 
by Sir Astley Cooper's method. At this 
time the arm was bent to a right angle, 
and quite stiff at the elbow-joint. 

Treatment. — Sir Astley Cooper 
thus describes his own method of re- 
ducing this dislocation : " The patient 
is made to sit upon a chair, and the 
surgeon, placing his knee on the inner 
side of the elbow-joint, in the bend of 

the arm, takes hold of the patient's wrist, and bends the arm. At the 
same time he presses on the radius and ulna with his knee, so as to 
separate them from the os humeri, and thus the coronoid process is 
thrown from the posterior fossa of the humerus ; and while this pressure 
is supported by the knee, the armis to be forcibly but slowly bent, and 
the reduction is soon effected." 

The plan recommended by Dorsey is nearly identical with that just described, 
only that, instead of the knee, he advises that the surgeon '' interlock his fingers 
in front of the arm, just above the elbow, and draw it backward.'' On the other 
hand, Liston and Miller recommend, as a better mode of procedure, that the 




Reduction with the knee in the bend of 
the elbow. 



636 DISLOCATIONS OF RADIUS AND ULNA. 

patient shall be seated upon a chair, and that the arm and forearm shall be 
pulled directly backward, so as to relax as completely as possible the triceps 
muscle, while counter- extension is made against the scapula. Skey says : " Ex- 
tension of the forearm should be made from the hand or wrist in a straight 
direction downward, as if for the purpose of simply elongating the arm." Pirrie 
prefers that an assistant shall grasp the forearm near its middle, instead of the 
wrist, and pull the arm straight forward, while at the same moment the surgeon 
seizes upon the olecranon process with the fingers of one hand, and, placing the 
palm of the other against the front and upper part of the forearm, pulls forcibly 
backward, so as to draw out the coronoid process from the olecranon fossa. 
Waterman recommends forced extension ; that is, bending the forearm forcibly 
back, as preliminary to flexion, with the view of lifting the coronoid process 
from the olecranon fossa. 1 

Having generally practised the method recommended by Sir Astley, 
and having usually succeeded in the first attempt and with the employ- 
ment of only moderate force, my predilections are in its favor ; yet I am 
not certain but that an equal experience with either of the other modes 
recommended might have changed these convictions. In recent cases 
very little force is generally requisite to accomplish the reduction, and it 
is not very material which of these several modes we adopt ; but in case 
of a failure by one mode, we ought immediately and without hesitation 
to resort to another, as the following case of a failure by flexion will 
illustrate : 

A lad, set. 11, fell in a gymnasium from a height of six feet, striking probably 
upon his hand. I saw him within twenty minutes, and found the arm in the 
usual position. I attempted immediately to reduce it by Sir Astley's method, 
but after a fair yet unsuccessful trial, I extended the forearm upon the arm 
until it was nearly straight, and then, with only moderate force, drew it promptly 
into place. 

If we still continue to encounter difficulties, the patient ought at once 
to be placed under the influence of an anaesthetic, and, if necessary, the 
pulleys should be employed. When the reduction is accomplished, which 
is indicated generally by the sudden slipping of the bones and by the 
restoration of the natural form to the elbow-joint, the surgeon, in order 
to confirm his opinion, must flex the forearm upon the arm to a right 
angle. , If the bones are in place, and there is not much swelling, this 
can generally be done without causing much, if any, pain ; but if it can- 
not be done, this fact furnishes presumptive evidence that the reduction 
is not effected. 

In one instance, however, of recent dislocation, this rule has not held good. 
A girl, set. 10, fell from a tree upon her hand. I found the usual signs charac- 
terizing this accident. Eeduction was accomplished readily by pulling at the 
hand moderately, with the forearm flexed, while my left hand pressed back the 
lower part of the humerus. After the reduction it was found impossible to flex 
the arm to a right angle without causing severe pain, and it became necessary, 
after placing it in a sling, to allow the hand to drop very low beside the body. 
A good deal of inflammation followed ; but in a few weeks the arm was well, only 
that for a period of two years or more the elbow remained very tender. 

On the other hand, an omission to apply this rule has often led the 
surgeon to believe the reduction accomplished when it was not. 

1 New Method of Eeduction of the Elbow, by Thomas Waterman, M.D., Boston Med. and 
Surg. Journ., vol. iv. Nos. 12, 13, new series, 1869. 



DISLOCATIONS OF RADIUS AND ULNA. 



637 



This has happened to me, and as it is the only instance in which I have 
omitted to adopt this test, and the only one also in which I have left a bone 
unreduced which I believed to have been reduced, it will be proper to state the 
case and its results more fully. A lad, set. 11, dislocated both bones backward. 
I saw him within two hours from the occurrence of the accident. The elbow 
was already considerably swollen and quite tender, but the signs of dislocation 
were very manifest. Seizing the wrist with one hand, and placing my knee 
against the front and lower part of the humerus, I pulled steadily for some time, 
and with much more force than is usually necessary, until at length two distinct 
and successive snaps were felt, such as one often feels when the two bones 
resume their sockets. Relinquishing my grasp, it was observed by myself and 
the parents that the deformity had disappeared. The reduction seemed to be 
complete, and so I announced. I then requested the lad to permit me to bend 
the elbow, and place it in a sling, but this he peremptorily refused to do, and 
ran away from me, nor would any arguments or entreaties persuade him to allow 
me again to touch it. I reassured the parents and child, however, that all was 
right, and left the house. During several successive days I saw the little patient, 
but although the arm remained swollen and very tender, I did not suspect the 
cause until the ninth day ; and on the tenth day, having placed him under the 
influence of chloroform, the reduction was easily and satisfactorily accomplished. 
The recovery was slow. As the end of six weeks I found the motions of the 
elbow-joint not completely restored, and the forefinger was partially paralyzed ; 
but from this condition it gradually recovered, and two months later the func- 
tions of the arm and hand were completely restored. The mistake in this 
instance was the more mortifying because I had just seen a case in a lad only a 
little older, in which another surgeon had committed the same error, and after 
the lapse of twelve or fourteen days I had myself made the reduction ; and I was 
fully awake, therefore, to the possibility of the mistake. 

The circumstance of the diminution and apparent disappearance of the 
deformity, and the sensation of a double click, can only be explained by 
assuming that originally the coronoid process was resting in the olecranon 
fossa, and that by manipulation the bones had been removed nearer their 
sockets, yet not actually reduced. The swelling, also, rendered more 
difficult a diagnosis which, now, nothing but the flexion of the forearm 
could have determined positively. 

If much time has elapsed since the occurrence of the dislocation, the 
reduction is accomplished with difficulty, if, indeed, it can be reduced 
at all. 

There are many cases upon record, however, in which surgeons have been 
successful after the lapse of many weeks, or even months. Boyer thought it 
was not possible to effect the reduction after four or six weeks ; but Cappelletti, 
of Trieste, succeeded after seventy days ;* Sir Astley Cooper, at three months ; 2 
Malgaigne, after three months and twenty-one days. 3 Roux succeeded in a case 
of a man twenty-two years of age, whose elbow had been dislocated five months. 4 
Blackman, of Cincinnati, informs me that he has reduced a lateral dislocation 
after five months. Brainard, of Chicago, reduced a dislocated elbow in a boy of 
nineteen years, after five months and thirteen days. In this case the surgeon 
who had first seen the patient supposed that he had reduced the dislocation. 5 
Gorre, Gerdy, and Drake succeeded in four cases after six months ; 6 1 have suc- 
ceeded at seven months ; and Starch claims to have been successful after two 
years and one month. 7 To which enumeration Denuce had added seventeen 



1 Cappelletti, Amer. Journ. Med. Sci., vol. xix., from Annal. Univ. de Med. for Oct. 1835. 

2 Sir Astley Cooper, on Dislocations and Fractures, Amer. ed., p. 388. 

3 Malgaigne, Amer. Journ. Med. Sci., vol. xxiii. p. 238. from Eevue Med., Dec. 1837. 

4 Roux, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Archives Gen., Dec. 1834. 

5 Brainard, Illinois and Indiana Med. Journ., 1847. 

6 Memoire sur les Luxations de Coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 

7 Denuce, op. cit., p. 87. 



638 DISLOCATIONS OF RADIUS AND ULNA. 

other examples said to have been reduced at various periods ranging from one 
month to one hundred and fourteen days. 1 I have reduced a number of these 
old dislocations, the last five of which will be briefly recorded. 

T. R., set. 35, was admitted to Bellevue Hospital with a simple dislocation of 
the radius and ulna backward, which had existed thirty-one days, but which 
had not been recognized. I reduced it by Sir Astley's method, the patient being 
under the influence of ether. Considerable force was required. 

J. G., set. 7, had a backward dislocation of the right radius and ulna, which 
had existed nine weeks. The arm was nearly straight and fixed. Having 
placed him under the influence of ether, assisted by Dr. Buck, of this city, I 
proceeded to flex the arm slowly, and after a few seconds, and when the elbow 
was bent about ten or fifteen degrees, the olecranon process separated at the line 
of epiphyseal union. In a few moments the reduction was completed, and the 
arm brought to an acute angle, but the olecranon had separated fully half an 
inch. We were quite certain that the ulna was perfectly reduced, but the head 
of the radius did not seem to occupy its original position fully. Only moderate 
inflammation ensued. Passive motion was soon commenced, and considerable 
motion of the joint was finally obtained. 

A gentleman, set. 30 years, consulted me on account of a dislocation which 
had then existed ten weeks, and which had not been recognized by his surgeon. 
In attempting to reduce the dislocation I fractured the olecranon, and brought 
the ulna into position, but I could not reduce the radius. Almost complete 
ankylosis of the elbow remains. A man was brought to me whose elbow had 
been dislocated eight weeks. Under ether, I succeeded in reducing the dislo- 
cation, but fractured the olecranon process in doing so. He has recovered very 
good use of the joint. I reduced the dislocation in the case of a woman, set. 
37 years, which had existed since a little more than seven months. I have seen 
her often since ; she has a somewhat limited but very useful motion of the joint. 
I assisted Dr. Sayre in reducing an old backward dislocation of these bones in 
the case of a boy. Other means having failed, while Dr. Sayre forcibly flexed 
the arm, I cut the triceps, after which the reduction was easily effected. Some 
months later the arm was nearly ankylosed at the elbow-joint, and it did not 
promise very well, so far as the usefulness of the member was concerned. Dr. 
W. F. Westmoreland, of Atlanta, G-a., has reported a case in which he succeeded 
readily in reducing a dislocation of the elbow backward, of five months' stand- 
ing, in a woman aged 22 years. The reduction was followed by great pain, a 
good deal of swelling, temporary impairment of circulation in the radial artery, 
complete paralysis of the little finger, and partial paralysis of the middle and 
ring fingers. On the fourteenth day, at which period the history of the case 
closes, all these symptoms were rapidly disappearing. 2 

The fact is in the main as stated by Boyer ; and if so many cases can 
be found in which surgeons have succeeded at a late period, they are not 
probably in the proportion of one to five as compared with the failures. 
But the failures have not received the same publicity. Nor, indeed, have 
all the severe accidents, such as violent inflammation, suppuration, gan- 
grene, and even death, been faithfully declared. 

Denuce says he has been able to trace out five or six examples in which, 
although the arm was reduced, grave accidents resulted, and Velpeau's patient 
actually died in consequence. Michaux, at the Hopital de Louvain, in 1841, 
in reducing an elbow dislocation, tore off the median nerve and brachial artery. 
Amputation was made and the life of the patient saved. 3 Dixi Crosby, of New 
Hampshire, has treated two cases of ancient dislocation of the forearm back- 
ward, by bending the elbow forcibly so as to break the olecranon process, after 
which the reduction was easily accomplished by extension. R. D. Mussey, of 
Cincinnati, has succeeded once in the same manner. 4 I have reported three 

1 Op. cit. 2 Westmoreland, Atlanta Med. and Surg. Journ., May, 1866. 

3 Debruyn, Des Luxations du Coude. These Inaug. Louvain, 1842, p. 77. 

4 Crosby, Mussey, Trans. Amer. Med. Assoc, vol. iii. p. 357. 



DISLOCATIONS OF RADIUS AND ULNA 



639 



similar examples. Malgaigne says that Cappelletti published an example in 
1835, and that Morel-Lavallee, Roux, and Maisonneuve had each met with the 
accident. 1 

In 1879, Trendelenburg, 2 in a girl, set. 15 years, with an irreducible disloca- 
tion of eight weeks' standing, having made an external incision, with a chisel 
separated the olecranon process from the shaft, and then reduced the dislocation. 
Observing now that when the arm was flexed there was a wide separation of the 
fragments, he again straightened the arm and brought the fragments together 
with a wire suture. He states that the results were satisfactory ! 

Voelker, 3 in an old incomplete backward and outward dislocation in a boy, 
set 13 years, attended with complete paralysis of the parts supplied by the ulnar 
nerve, severed the olecranon with a saw and then wired the fragments together. 
The result of the operation was a certain degree of improvement in the motions 
of the arm, and the disappearance of the paralysis. 

In 1889, Gerdy,* in a dislocation of six months' standing, divided subcuta- 
neously the triceps and the adjacent adhesions, but he was still unable to 
reduce the dislocation. 

Maisonneuve 5 and Blumhart 6 only effected the reduction after the most exten- 
sive tegumentary, muscular, and ligamentous dissections. Von Wahl, 7 in two 
cases made an external incision, and having divided in one case both of the 
lateral ligaments, and in the other the external only, and having destroyed the 
adhesions, was unable to effect reduction. He proceeded, therefore, to practise 
resection of the joint. 

Emmert 8 and Boeckel 9 have each practised resection in similar cases ; and 
Oilier 10 has'three times resorted to the same expedient in old irreducible dislo- 
cations. 

All of these latter surgical expedients should be reserved for excep- 
tional cases. Not one of them is wholly free from danger, and the results 
are not in all cases such as might be hoped for. Moreover, experience 
has abundantly shown, and especially when the accidents have occurred 
in early life, that a persistence of the dislocation is not incompatible with 
the subsequent formation of a new and very useful joint. 

In a recent case, the dislocation being reduced, it may be a matter of 
prudence, sometimes, to apply a right-angled splint, first carefully padded, 
to the palmar surface of the arm and forearm ; remembering, however, 
that considerable swelling will soon occur, and that it ought not, there- 
fore, to be bandaged to the limb very tightly. At least once a day it 
should be removed, and the arm examined ; and in very few cases can 
it be necessary or judicious to continue its application beyond one week. 
At the same time, if there is any especial tendency in the radius to 
become displaced backward, owing to a rupture of its annular ligament, 
this must be prevented, if possible, by a compress and bandage Some 
surgeons regard these precautions as necessary in all cases, but I have 
seldom employed any splint or bandage whatever, nor have I ever had 
reason to regret this omission, Finally, we are to place the arm in a 
sling, and adopt such measures as are calculated at first to reduce the 



1 Malgaigne, od. cit., Paris ed., 1855, vol. ii. p. 144. 

2 Trendelenburg, Centralblatt fur Chir., 1880, No. 52, p. 833. 

3 Voelker, Deutsche Zeitschriftfur Chir., Bd. 12, Hft. 6. 

* Gerdy, Annal. de Chir. Francaise et Etrang. t. 2. p. 151. 

5 Maisonneuve, Poinsot, op. cit., 918. 

6 Blumhart, Gaz. Med. de Paris, 1847, p. 238. 

i Von Wahl, St. Petersburger med. Wochenschrift, 1879, No. 23, p. 221. 

8 Emmert, Eev. Med-. Chir.. t. 3, p. 177. 

9 Boeckel, Frag, de Chir., Paris, 1882, p. 85. 

10 Oilier, Per. Mens, de Chir., 1882, pp. 722-734. 



640 DISLOCATIONS OF R4DIUS AND ULNA. 

inflammation ; and at a very early day we ought to begin to move the 
elbow-joint, in order to prevent ankylosis. 

§ 2. Dislocations of the Eadius and Ulna Outward (to the Radial Side). 

(a) Complete Outward Dislocations. — The large majority of outward 
dislocations of the forearm are incomplete ; indeed, only nine examples 
of a complete dislocation have been collected by Denuce, including two 
seen by himself. 1 In his last memoir he has added four more. 

Malgaigne has recorded two ; 2 Molliere, of Lyons, has reported one, 3 Amboni, 4 
Hatry, 5 Bertin, 6 have each reported one. Andrews 7 has also reported one, and 
Salleron one, 8 Osborne one, 9 Varick one, 10 Wylie one. 11 Dr. Erskine Mason has 
reported two, in children of seven and twelve years respectively, and he refers 
to another reported by one of his colleagues at Bellevue in the Medical Eecord 
for October 9, 1875, in the person of a lad, set. 17 years, 12 making in all nine- 
teen cases. Dr. Varick's case is reported as follows: G. K., set. 9 years, was 
thrown violently from a wagon, striking on his head and back, with his left 
arm behind him in a state of flexion. He was brought to my office within ten 
minutes after the receipt of the injury, and, consequently, in the most favorable 
condition for manipulation, no swelling of the soft parts having yet occurred. 
The forearm was in a state of semiflexion, supported by the hand of the opposite 
side, the ulna lying to the outer side of the external condyle with slight poste 
rior projection of the olecranon. The olecranon, coronoid process, and greater 
sigmoid cavity could be distinctly defined, and the head of the radius, in its 
normal relations to the ulna, could be felt rotating subcutaneously on pronating 
and supinating the forearm. Free motion of the forearm in every direction was 
present, giving the impression of being attached to the arm solely by the soft 
parts. The projection of the internal condyle was out of all proportion to what 
is seen in cases of incomplete dislocation. The trochlea, coronoid depression, 
and the olecranon depression were distinctly recognized. Complete dislocation 
of the radius and ulna outward was diagnosticated, which diagnosis was cor- 
roborated by my friend, Dr. B. A. Watson, who was present and assisted in 
the reduction. The patient was placed fully under the influence of ether, and 
moderate extension, combined with lateral pressure, effected the reduction with- 
out difficulty. The subsequent treatment consisted of rest and cold irrigation 
for a few days, followed by passive motion of the parts, which resulted in perfect 
recovery. The amount of inflammation which followed the injury was exceed- 
ingly slight, due unquestionably to the prompt reduction of the dislocation. 

Dr. Wylie, who was at that time House Surgeon at the Long Island College 
Hospital, Brooklyn, relates the case as follows: E. B., aged 38 years, fell with 
one arm raised, striking on the inner side of the elbow ; at the same moment a 
barrel of fish, weighing two hundred and fifty pounds, fell over, striking the 
arm about three inches above the external condyle. Upon rising he found the 
arm flexed at a right angle, pronated, and immovable at the elbow-joint. No 
attempt at reduction was ever made, nor was there any retentive apparatus 
applied. He put the arm in a sling, and after a couple of months he commenced 
using it a little. At the end of two years his arm was sufficiently recovered to 

1 Denuce, Mem. sur Lux. des Coudes. Paris, 1854. 

2 Malgaigne, op. cit. 

3 Molliere, Monthly Abstract Med. Sci. vol.i. p. 269, 1874. 

4 Amboni, Annal. Univ. di Med., July, 1872. 

5 Hatry, Lyon Med., t. 18, p. 13, 1875. 

6 Bertin, Union Med., 1876, p. 609. 

i Andrews, Med. Eecord, Oct. 23, 1875, p. 720. 

8 Salleron, Pingaud, Art. Coude, Die. Encye. Sci. Med., ser. 1, t. 21. 

9 H. B. Osborne, Hosp. Gazette, Nov. 29, 1879, p. 613. 

10 T. R. Varick, Med. Record, Nov. 1, 1867, p 387. 

11 "W. Wylie, Med. and Surg. Rep., March 22, 1879, p. 250. 
32 Mason, Med. Record, April 10, 1880, p. 397. 



DISLOCATIONS OF EADIUS AND ULNA 



641 



permit him to return to his sailor life, which he followed up to six months ago, 
when he was admitted to the Long Island College Hospital, for other injuries. 
At the present time, seventeen years after the accident, the inner border of 
the olecranon process rests upon the external border of the humerus, above the 
external condyle, where, probably, an articular facet has been developed. Just 



Fig. 404. 




Dr. Wylie's case. 
A. Badius; B. Olecranon process ; C. Lower end of humerus. 

anterior to and to the inner side of this is the head of the radius, which can be 
recognized by sight, but more surely identified by touch. The internal condyle 
of the humerus projects greatly, and the trochlea can be distinctly felt. When 
extended, the radial border presents a gentle outward inclination from the 
elbow down. This may be greatly increased or diminished by manipulation. 



Fig. 405. 





The same. Arm nearly extended; the lower end of the humerus projecting below. 

This extremity is one and three-quarters of an inch shorter than the other. (This 
is my own measurement, and differs a little from that given by Dr. Wylie.) The 
patient has full control of this limb, can flex or extend, pronate or supinate it 
nearly as well as the other, and he thinks it is in every particular as serviceable 
as the other. 

Causes. — This accident has been produced generally either by a fall 
upon the hand or upon the elbow. In the latter case, it has been occa- 
sionally noted that the force of the concussion was received upon the 
internal portion of the elbow. 

Pathological Anatomy. — Two varieties of this accident have been 
recognized ; one in which the sigmoid fossa of the ulna is situated exter- 

41 



642 DISLOCATIONS OF RADIUS AND ULNA. 

nally and above the epicondyle, and one in which the sigmoid cavity 
embraces the epicondyle externally or is situated below it ; while the 
head of the radius is carried forward by the resistance offered by the 
pronator muscles. 

[A third variety has been described as " infra-epicondylar." The bones are 
displaced upward and are found on the outer border of the humerus. The 
diameter of the humerus is increased, the forearm is markedly shortened and 
strongly flexed.] 

Symptoms. — There is usually little or no difficulty in recognizing the 
nature of this dislocation, since the articular projections are easily felt 
and seen beneath the integuments. The deformity is very marked, and 
in the case of the supra-condyloid dislocation, the arm is shortened, the 
forearm is flexed and rotated inward, and the motions of the joint are 
limited ; while in the infra-condyloid variety, the forearm is very little 
or not at all shortened; it is flexed also,, and the pronation is more 
extreme. 

Prognosis. — In most of the examples reported, the reduction has been 
effected, and the functions of the arm have been restored ; and even 
when not reduced, the usefulness of the arm has not been diminished in 
such a degree as might naturally have been expected. In the case ot 
Baker, reported above, the arm seemed after the lapse of seventeen years 
to be as useful as before. 

Treatment. — -Extend the forearm upon the arm, with the hand in a 
position of forced supination, and make traction ; and at the same time 
make direct pressure with the thumbs upon the projecting point of the 
ulna. In case the dislocation is infra-condyloidian, the hand may be 
maintained in a position of pronation during this procedure. 

(b) Incomplete Outward Dislocations. — Incomplete dislocations must, 
in this case, be regarded as typical ; but even these are by no means 
frequent. 

Causes. — A careful examination of a large number of recorded exam- 
ples, and of those which have come under my own eye, renders it certain 
that a majority of these accidents result from a blow received directly 
upon the inner side of the forearm or upon the outer side of the humerus, 
or from the action of two forces pressing in an opposite direction. Ot 
course, these forces must act upon the bones somewhere in the neighbor- 
hood of the elbow-joint. Occasionally it has been produced by a fall 
upon the hand ; sometimes by a violent twist of the arm, as when the 
hand is caught in machinery ; and in other cases it has been found con- 
secutive upon a dislocation backward, being produced in the attempts 
made to accomplish reduction of this latter form of dislocation. 

Pathological Anatomy. — In most of the examples of simple incomplete 
outward dislocation of the forearm, the great sigmoid cavity of the ulna 
still embraces the lower end of the humerus ; but instead of reposing 
upon the trochlea fairly, it is carried outward half an inch or more, so as 
to rest its central crest upon the depression which separates the trochlea 
from the lesser or radial head of the humerus. If the annular ligament 
remains unbroken, the radius is displaced in the same direction and to 
the same extent. Occasionally, however, where the violence has been 



DISLOCATIONS OF RADIUS AND ULNA 



643 



greater, the central crest of the great sigmoid cavity rests fairly upon the 
condyle, or upon the articulating surface of the humerus where the head 
of the radius was formerly applied, and the dislocation approaches more 
nearly to the character of a complete dislocation. At the same time, 
owing, perhaps, to the resistance afforded by the skin, or some of the 
ligaments, the head of the radius may be thrown either forward or back- 
ward, so as to be out of line with the ulna. Such a displacement gener- 
erally implies a rupture of the annular ligament. 

We have now only to suppose the action of a more considerable force 
in the same direction to render the dislocation complete ; in which case 
the upper end of the radius is sometimes thrown completely forward, and 
its head may even be found resting in front of the ulna, occasioning an 
extreme pronation of the forearm and hand. The anconeus and brachialis 
anticus are the only muscles in either of these dislocations whose fibres 
are generally much disturbed; the biceps and triceps being made also to 
traverse the articulation a little more obliquely. In examples of frac- 
ture of the external condyle, the condyle being carried outward, the 
radius may remain in contact with the trochlea, and the ulna may accom- 
pany it in this outward displacement ; but this must be regarded as a 
fracture rather than as a dislocation. 



Fig. 406. 



Fig. 407. 





Forms of outward dislocation of radius and ulna. 



[Poumet presented a specimen of this dislocation, of long standing, to the 
Societe Anatomique ; the ulna displaced outward ; has completely left the 
trochlea; latter contains a large sesamoid bone; external articular surface of 
sigmoid cavity in relation with capitellum; radius displaced outward and for- 
ward. (Fig. 407.)] 

Denuce, Malgaigne, A. Cooper, and others have preferred to speak of the dis- 
location backward and outward as a distinct form or species of dislocation. I 
prefer to regard it as only a variety of the outward dislocation, since it may, and 



644 DISLOCATIONS OF RADIUS AND ULNA. 

no doubt often does, occur consecutively upon a simple incomplete outward dis- 
location ; and if the dislocation outward is complete, the bones of the forearm 
can scarcely fail to be drawn more or less upward. Sometimes, also, it has been 
consecutive upon a simple backward dislocation, or upon unsuccessful attempts 
at reduction where the form of dislocation was originally backward ; yet, as it 
does not so naturally follow upon a complete backward dislocation as upon a 
complete outward dislocation, I find sufficient reason for studying its mechanism 
in this place. 

The beak of the olecranon process not only, but a large portion of 
the body of this process, now lies above and behind the condyle; the 
brachialis anticus becomes more stretched, if not actually torn ; and the 
biceps is laid against the articulating surface of the humerus ; but the 
triceps becomes again relaxed ; as in simple dislocation backward and 
upward. In all these dislocations the capsular ligaments are more or 
less extensively torn, but the principal arteries and nerves do not gener- 
ally suffer greatly, if at all. 

Symptoms. — The forearm is usually flexed to about the same angle at 
which I have found it in dislocations backward ; once I have found it 
nearly or quite straight ; occasionally it is flexed to a right angle. In all 
the cases seen by me the forearm has been pronated, and the elbow-joint 
has been very immovable. The most striking diagnostic sign, however, 
consists in the unnatural form of the elbow-joint, which is so remarkable 
as not to be easily misunderstood. The internal condyle of the humerus 
(epitrochlea) projects strongly to the inner side, leaving a deep depression 
below ; while upon the other side, the head of the radius, with its cup- 
like extremity, can be distinctly felt, and made to rotate outside of its 
socket. The olecranon process, driven from its fossa, projects more or 
less posteriorly, and even the fossa itself may sometimes be plainly felt. 

A girl, 12 years old, had fallen upon the inside of her elbow, producing an 
incomplete dislocation outward of the forearm. The forearm was bent upon the 
arm about fifteen degrees, and immovably fixed. The head of the radius could 
be distinctly felt external to and a little in front of the outer condyle, while the 
olecranon process of the ulna, which rested upon the back and outer surface of 
the humerus, was less distinctly felt than in the opposite arm. The inner con- 
dyle projected sharply to the inside, and the olecranon fossa was plainly felt 
with the fingers. The child was suffering very little pain. Seizing the wrist 
with my right hand and the lower end of the humerus with the left, and making 
moderate extension in these opposite directions, the bones easily, and after only 
a moment's effort, resumed their places. Her recovery was rapid and complete. 

If the dislocation is complete, the position of the arm is usually the 
same, but the pronation of the hand is greater, and the projection of the 
inner condyle more striking. If now the bones, by a continuance of the 
original force, or by the action of the triceps, are drawn upward also, the 
arm becomes a little more flexed, and the olecranon process more promi- 
nent, while the length of the whole limb is sensibly diminished, 

Prognosis. — In recent cases, and where no complications exist, the 
reduction is generally easily effected. 

M. Thierry claims to have reduced an outward and backward semi-luxation 
after eight months. A patient of whom Debruyn has spoken was not so fortu- 
nate. On the 16th of April, 1841, a lad, aet. 18, fell upon the palm of his hand 
and semi-luxated both bones outward and backward ; on the following morning 



DISLOCATIONS OF RADIUS AND ULNA. 645 

a surgeon attempted to reduce the dislocation, and the attempt was repeated on 
the next day by another surgeon ; but on the day following this last attempt, 
gangrene ensued in consequence of the great violence employed by the surgeons, 
and although the limb was amputated, the patient died. The autopsy showed 
that both the brachial artery and the median nerve were torn asunder, and that 
the tendons of the biceps and the brachialis anticus were slipped behind the 
outer condyle, probably having been thrown into this position during the violent 
twistings to which the arm had been subjected. 1 

I have seen three examples of semi-luxations upward and outward which the 
medical attendants had failed to reduce. The first was in the case of a lad, 14 
years old, who had fallen upon the palm of his left hand. The surgeon who was 
immediately called made extension, and supposed that the reduction was accom- 
plished. The lad was brought to me a few months after the accident. The arm 
was slightly flexed, and neither prone nor supine. There existed only a slight 
motion at the elbow-joint. I did not think it worth while to make any attempt 
at reduction. Several years after this I had an opportunity of examining the 
arm again. He had now recovered considerable motion in the joint, but he 
could not tie his cravat. Pronation and supination were perfect. 

In the second example, a lady, set. 33, had fallen upon the inside of her 
elbow, and reduction not having been accomplished, I found her, nine weeks 
after the accident, with scarcely any motion at the elbow-joint, and complaining 
of a numbness in the forearm and hand. 

The third instance of unreduced semi-luxation I will relate more at length : 
F. B., aged twenty-two years, fell a distance of about five feet, striking upon the 
palm of his hand, his arm being extended in front of him. On rising, he found 
his arm forcibly flexed and abducted. He straightened it without difficulty, and 
it assumed the position it now occupies. A physician was called and saw the 
patient an hour and a half after the accident, who pronounced it a case of dis- 
location of the radius and ulna, and made efforts at reduction, which he con- 
tinued from 8: 30 A. M. until 2 p. M., a period of five and a half hours, to no 
purpose, when he abandoned the attempt. During the attempt at reduction, the 
extension was made at times with the arm flexed, and at others extended. At 
9 P. M. another physician was called, who made efforts at reduction until 3 A. M., 
upward of six hours, at which time he also abandoned the attempt. On the 
third day another physician, the patient being under the influence of ether, 
made efforts at reduction for twenty minutes, when he pronounced it in place, 
and applied a bandage. From the patient's account, the arm was swollen to 
such an extent as to render this point difficult to determine. On the fifth day 
the first physician was called, and, believing that he discovered a grating, pro- 
nounced it a fracture of the external condyle. Four months after the accident 
the limb presented the following appearances : The " forearm extended upon 
the arm ; looking at the limb along its radial margin, we notice a gentle out- 
ward inclination of the forearm from the elbow down, but by manipulation this 
may be greatly increased ; the power of pronation and supination is not affected ; 
the inner condyle projects an inch to the ulnar side ; the head of the radius, 
completely removed from its socket, projects to an equal extent on the radial 
side. The top of the olecranon process is an inch higher than the top of the 
inner condyle, so that the radius and ulna are carried upward as well as out- 
ward." 

I believe that the external condyle was not broken, as in that case the arm 
would be permanently deflected outward to a much greater extent. For, although 
this arm may be deflected outward by the surgeon to an angle of 135°, still the 
degree of mobility which exists would be adverse to the supposition of its being 
a fracture of the external condyle. The condyles also can be plainly felt in 
their natural situations, which would not be the case if a fracture of the external 
condyle existed. The patient was advised not to submit to any further attempts 
at reduction. 

The following will serve as an illustration of a recent accident of this char- 
acter: A boy, set. 8, fell while wrestling, his companion falling upon his arm. 
I found the forearm slightly flexed, pronated, and both radius and ulna thrown 

1 Denuce, op. cit., p. 103. 



646 DISLOCATIONS OF RADIUS AND ULNA. 

over to the radial side and carried upward. Pressing firmly upon the radius 
from the outside, the bones assumed suddenly the position of a backward and 
upward dislocation, from which position they were readily reduced to their 
original sockets by simple extension. 

Treatment. — In relation to the treatment of these accidents I have 
little to add to what has already been said of the treatment of disloca- 
tions backward. The reduction, if effected at all, has generally been 
accomplished by moderate extension, or by extension combined with 
lateral pressure. If the head of the radius is in front of the humerus, 
or of the ulna, the hand should be first supined, and then the extension 
should be applied. In some cases the reduction has been effected by 
placing the knee in the bend of the elbow and flexing the forearm, while 
the surgeon was making extension from the hand. 

§ 3. Dislocations of the Radius and Ulna Inward (to the Ulnar Side) ; 

Always Incomplete. 

This form of dislocation has generally been considered as much more 
rare than the incomplete dislocation outward, a fact which may perhaps 
find a sufficient explanation in the peculiar form of the trochlea, the inner 
half of which rises much higher than the outer, forming thus an elevated 
inclined plane, over which the articulating surface of the ulna must rise 
before the dislocation can occur. 

Hahn and Sprengel have, however, observed the incomplete inward disloca- 
tion more often than the incomplete dislocation outward. 

Like the opposite dislocation, the typical form of the accident is that 
in which the displacement is incomplete ; indeed, no example of a com- 
plete inward dislocation has, I think, been yet recorded. 

Causes. — A fall upon the hand or forearm, a blow upon the radial side 
of the forearm near its upper end, or upon the ulnar side of the arm 
near its lower end, a violent w T renching or rotation inward, of the forearm, 
are among the causes which may occasion this dislocation. 

Pathological Anatomy. — The ridge which divides antero-posteriorly 
the greater sigmoid cavity of the ulna, having been driven over the ele- 
vated inner margin of the trochlea, falls down upon the epitrochlea, so 
as, in some sense, to embrace it instead of the trochlea ; while the head 
of the radius passes inward also, and is made to occupy the trochlea, 
from which the ulna has escaped. Generally the head of the radius is 
found in the same line with the ulna (Fig. 408), but it may suffer a dis- 
location and be found a little in advance of the ulna, or possibly a little 
back of the ulna. 

I choose also to regard the semi-dislocations inward and upward as 
only a variety of the semi- dislocation inward ; in which form of the acci- 
dent the coronoid process of the ulna is thrust upward above the epicon- 
dyle, and the head of the radius occupies the olecranon fossa, or rests 
upon the back of the humerus somewhere in this vicinity. In addition 
to the injury suffered by the ligaments and muscles, the ulnar nerve in 
both varieties of inward dislocation is peculiarly liable to contusion, in 



DISLOCATION'S OF RADIUS AND ULNA, 



647 



consequence of its being crushed between the olecranon process and the 
epitrochlea. As in fractures of the external condyle, so in fractures of 



Fig. 408. 



Fig. 409. 





Most frequent form of in- 
complete inward dislocation 
of the forearm. 



Broca's case of incomplete dislocation inward ; a, epitrochlea ; 
c, b, olecranon ; d, head of radius. 

the internal condyle the radius and ulna are apt 
to suffer a lateral displacement also ; these ex- 
amples are more properly to be considered as 
fractures rather than dislocations. 



[Broca dissected an old incomplete dislocation in- 
ward. A new joint had been formed which admitted 
of flexion and extension nearly complete ; though the 
lateral and annular ligaments had disappeared and a new capsule seemed to have 
been formed. The external appearances are seen in Fig. 409.] 

Symptoms. — If the displacement is only inward, the olecranon process 
can be felt projecting upon the inner side, and completely concealing the 
epicondyle ; while the head of the radius, having abandoned its socket, 
may be felt indistinctly in the bend of the arm. The external condyle 
(epicondyle) is remarkably prominent. The forearm is generally more or 
less flexed. The natural outward deflection of the forearm is also lost, or 
it may be even inclined slightly inward. This phenomenon is explained 
by the position of the epicondyle, upon which the greater sigmoid cavity 
noAV rests, allowing the ulna to overlap a little upon the humerus ; render- 
ing the forearm actually somewhat shorter along its ulnar margin, although 
the head of the radius may still occupy the summit of the trochlea. If 
the bones are displaced upward, as well as inward, a considerable 
shortening is declared, and the head of the radius may now be felt behind 
the trochlea, or over the olecranon fossa. 

In three of the four examples seen by Malgaigne, all of them ancient, the 
forearm was in a state of supination. 

A girl, set. 5, fell, striking upon her right elbow. A physician was called, who 
supposed it to be a fracture. Five weeks later it was seen by Prof. Prewitt, of 
St. Louis, Mo. The forearm was flexed, and could not readily be extended 
beyond a right angle ; it occupied a position midway between pronation and 



648 DISLOCATIONS OF RADIUS AND ULNA. 

supination ordinarily, but could be supinated and pronated perfectly. The 
olecranon process was on a line with the extreme point of the inner epicondyle, 
and the head ot the radius could be felt below the olecranon fossa. A finger 
could be pressed readily into the fossa. A small, sharp spiculum of bone had 
been torn off, and lay loose over the external condyle, which was very promi- 
nent. Atttempts were made by Dr. Prewitt to reduce the dislocation under the 
influence of an anaesthetic, but without success. 1 . 

The following example of this dislocation, unreduced after the lapse of 
fourteen years, is reported by Dr. T. H. Squier, of Elmira, N. Y.: T. C, now in 
his nineteenth year, was 4 years and 10 months old when he fell from a pile of 
boards about as high as a man's shoulder. According to his statement, given at 
the time, his right arm caught between the boards, and, in falling, he turned a 
somersault. The mother, to whom the child immediately ran, grasped his arm 
which he said was broken, and found that it would roll and turn in various ways. 
When the surgeon arrived, three hours afterward, the arm was very much 
swollen, and the accident was supposed to be a fracture. At present the flexion 
and extension are perfect. The forearm has an inward deflection of a hand's 
breadth more than the other. The power of pronation is complete, but the 
forearm and hand cannot be supinated entirely. The external condyle is very 
prominent, but the internal is almost hid by the olecranon, which projects inward 
nearly as far as the point of the epicondyle. The finger can be laid in the ole- 
cranon fossa behind, and all the back part of the trochlea can be distinctly traced. 
By flexing the forearm slowly, as it approaches a right angle, the tendon of the 
triceps may be felt, lodged, as it were, on the back part of the point of the epi- 
condyle ; and by continuing the flexion, the tendon suddenly slips over this 
point and places itself on the anterior aspect of the arm. When the forearm is 
fully flexed, the tendon is advanced full three-quarters of an inch in front of 
the epicondyle. The arm is very serviceable, but invariably pains him after a 
hard day's work. 

[The following case was reported by Hauck, of St. Louis : P. B., aged 13, was 
brought to our office at noon on the 7th of September. A half hour previous, 
while playing, he slipped on a banana peel and fell. Striking on the point of 
his right elbow, and turning on this as a pivot, he struck his right cheek and 
forehead. On examination, I found the external condyle prominent, olecranon 
lying over internal epicondyle, and the head of the radius on the trochlea, where 
it could be felt rotating. A depression existed between the olecranon and the 
external condyle. Passive flexion and extension were very limited ; pronation 
and supination possible but very painful. Reduction was easily accomplished 
by drawing on flexed forearm in a line with the humerus, and pushing the 
olecranon outward, while the humerus was being firmly held by an assistant. 
Immediately after reduction the severe pain disappeared, and extension and 
flexion, pronation and supination were almost perfect, but painful. The radius 
had returned to its normal position. 2 ] 

Prognosis. — Malgaigne was unable to reduce the bones in a recent 
case of incomplete internal dislocation which came under his own notice. 
Triquet succeeded in a child seven years old, on the fifteenth day, after 
many trials ; but the movements of the elbow-joint were never restored. 
Debruyn succeeded on the fifth day, but not without difficulty ; Prewitt 
failed at the end of five weeks ; the case reported by Squier was mis- 
taken for a fracture, and no attempt at reduction was made ; and in a 
case seen by Velpeau, reduction was easily accomplished, and on the 
eighth day the patient was dismissed. 3 Of the four examples of inward, 
backward, and upivard dislocation seen by Malgaigne, not one was ever 
reduced ; but as the history of them all is not complete, it is by no 

i Prewitt, St. Louis Courier of Med., Jan. 1879, p. 43. 

2 The Weekly Medical Kev„ Nov. 28, 1885. 

3 Denuce, op. cit., pp. 154-156. 



DISLOCATIONS OF RADIUS AND ULNA 



649 



means to be inferred that the reduction could not have been easily accom- 
plished, at least in some of them, at the first. Nor, with such imperfect 
details before us, can we understand fully what complications may have 
existed, such as would perhaps render these exceptional rather than 
illustrative examples. 

One of these patients had a completely ankylosed elbow at the end of two 
years, but pronation and supination were preserved. In the case of another, 
however, even flexion and extension were as perfect as in the normal condition. 

Treatment. — The indications of treatment are the same as in semi-dis- 
locations outward, with only such slight modifications as the judgment 
of every surgeon must naturally suggest. 

I prefer to employ, by way of illustration, the example diagnosticated by Vel- 
peau. A. G., set. 22, entered the hospital with an incomplete inward dislocation 
of the forearm which had just occurred. The hand and forearm were in a state 
of forced pronation, half-flexed, and the whole limb from the elbow downward 
was deflected inward. There were present, also, all the other usual signs of this 
dislocation, and Yelpeau had no doubt as to its true character. In order to 
accomplish reduction, one assistant made counter-extension upon the arm, while 
a second made direct extension upon the forearm. At first the tractions were 
made in the direction of the forearm (flexed and prone), but gradually the arm 
was straightened and supinated. Then the surgeon, seizing with one hand the 
superior extremity of the forearm and with the other the inferior extremity of 
the arm, acted forcibly upon the two portions in opposite directions, and imme- 
diately the reduction was effected with a noise. 1 

§ 4. Dislocations of the Radius and Ulna Forward. 



Sir Astley Cooper, Vidal (de Cassis), and others, have denied that 
this dislocation was possible without a fracture of the olecranon process ; 
but Monin, Prior, Velpeau, Canton, 2 and Denuce have each reported one 
example, also Wittlinger, Flaubert, Secrestan, and Cannin, 3 so that its 
existence may now be considered as estab- 
lished. . Fig. 410. 

The following is a summary of the facts in 
Velpeau's case : A. C, set. 23, was knocked down 
by a carriage, the wheel passing over the right 
arm. The arm was found in a right-angled posi- 
tion, and it could neither be flexed nor extended ; 
the forearm was strongly supinated; the project- 
ing angle usually made by the olecranon process 
was replaced by the irregular extremity of the 
humerus; the forearm was shortened upon the 
arm ; the head of the radius resting in the coro- 
noid fossa, and the olecranon process being also 
carried upward and a little outward. Eeduction 
was easily accomplished, and the patient left on 
the nineteenth day, with only a slight remaining 
stiffness in the joint. 4 

A case is reported to have come under the 
observation of Mr. J. W. Langmore, House 

Surgeon at the University College Hospital, London. It was occasioned by 
a fall upon the elbow. The reduction of the ulna was easily accomplished 

1 Denuce, op. cit., p. 155. 2 Dublin Quart. Journ. of Med. Sci., Aug. 1860. 

3 Poinsot, op. cit., p. 939. i Denuce, op. cit., p. 110. 




E. Canton's case of dislocation of 
the radius and ulna forward. 



650 DISLOCATIONS OF RADIUS AND ULNA. 

by placing the knee in the bend of the elbow and flexing the arm. The radius 
was then reduced by pressure and extension. 1 Chapel has reported a case of 
dislocation forward and outward, which he readily reduced soon after it occurred, 
while Colson, Leva, Ancelon, and Guyot have each reported one example of 
sw6-luxation forward, in which the extremity of the olecranon process has been 
found resting upon the extremity of the humeral trochlea. 2 In a case of incom- 
plete dislocation forward, mentioned by Date, 3 the internal condyle was broken. 
The fracture of the olecranon as accompanying this accident, has, according to 
Poinsot, only been observed in six cases, namely, by Richet, Velpeau, Guerin, 
Morel-Lavallee, and Guerre. In the latter case, according to Pingaud, the dis- 
location was easily reduced, and the result was a very useful limb. 

Causes. — This accident seems to have been, in most cases, caused by 
a fall upon the elbow while the forearm was forcibly flexed. 

In Date's case, however, a boy 14 years old, the fall was upon the palm of the 
hand. 

In case it is caused by a fall upon the elbow, with the arm in a posi- 
tion of forced flexion, the olecranon receives the impact, and this fact, 
aided perhaps by torsion and abduction of the forearm, drives the bones 
forward. 

Pathological Anatomy. — In the case reported by Canton, amputation 
became necessary, and an opportunity was thus afforded to make a care- 
ful dissection of the parts involved in the injury. At the time of the 
accident the arm was in a position of forced flexion, with the forearm 
twisted upon the chest. The olecranon was found lying in front of the 
little head of the humerus, the radius was in a position of supination, 
preserving its normal relations with the ulna. The anterior ligament 
was torn, as were also the posterior and lateral ligaments. The annular 
and oblique ligaments were intact. The triceps was torn from its inser- 
tions. The tw T o external radial and most of the muscles originating at 
the epicondyle were more or less torn. The biceps and brachialis anticus 
were in a state of tension. The larger vessels were unbroken. The 
ulnar nerve was torn opposite the condyle. The median nerve had suf- 
fered only slight lesions. 

[Symptoms. — The forearm is lengthened with flexion, which may be 
slight or considerable ; there may be quite free movement and extension 
to the greatest degree may be possible without pain ; there is a depres- 
sion at the olecranon fossa, and some flattening at the sides of the elbow.] 

Treatment. — If the dislocation is complete, and the forearm is length- 
ened and flexed upon the arm, the reduction should first be attempted 
by violent flexion, or by flexion combined with extension from the wrist, 
and counter-extension from the lower portion of the humerus. If the 
dislocation is incomplete, and the forearm is extended upon the arm, the 
reduction may be readily accomplished by extension alone, or by mod- 
erate flexion. 

Dislocation of the Radius and Ulna Forward, with Complete Retro- 
version of both Bones. — Maisonneuve 4 has reported a case in which both 

1 New York Med. Kecord, March 1, 1867, from the London Lancet. 

2 Denuce, p. 120. 

3 Date, The Lancet, 1872, vol. ii. p. 97. 

4 Maisonneuve, Gaz. des Hop., 1867, No. 37. Poinsot, op. pit., p. 944. 



DISLOCATIONS OF RADIUS AND ULNA. 651 

bones being dislocated forward, the ulna was turned upon itself, so that 
its sigmoid cavity embraced the articular extremity of the humerus. The 
patient, a woman, get. 43, had fallen upon the internal margin of the 
humerus. The inferior extremity of the humerus projected posteriorly, 
covered only by the skin. The triceps, slightly stretched, was carried 
outward and forward, and lay in front of the condyle. The olecranon, 
unbroken, was in front of the trochlea ; its great sigmoid cavity embraced 
the articular pulley. The radial cup was entirely hidden. The forearm 
was forcibly pronated. Reduction was effected by carrying the forearm 
outward, by which the olecranon was disengaged, and the cup of the 
radius presented itself externally ; continuing to press the forearm out- 
ward, the olecranon now abandoned the trochlea, embraced the condyle, 
and then slid outward. The forearm at once took the position of supina- 
tion, and the great sigmoid cavity again presented forward, passing 
behind the humerus. The dislocation, having thus been transformed 
into a backward dislocation, was easily reduced. 



. Diverging" Dislocations of the Radius and Ulna, 
(a) Dislocations of the Radius Forward, and Ulna Backward. 

This accident was first recognized, according to Malgaigne, by M. 
Michaux and M. Bulley in 1841, when each of these gentlemen met 
with a case. 

Michaux's patient was a man, 44 years old, who had fallen eight feet, striking 
upon his elbow while it was carried away from his body. At first the dislocation 
of the radius was not recognized, but having reduced the ulna by traction, he 
discovered the head of the ulna in front, which was finally reduced by direct 
pressure made upon it with the thumb. M. Bulley's patient was a male, also, 
aet. 28, who had been thrown violently upon the palm of his hand. The forearm 
was slightly flexed, and could not be moved from this position without causing 
great pain. The coronoid process rested in the olecranon fossa and the head of 
the radius in the coronoid fossa. With slight traction the ulna was reduced, 
and afterward the radius was reduced by methodic processes. 

M. Mayer reported a case which was not recognized until the fourteenth day, 
and then he found himself unable to reduce it. 1 Denuce mentions these three 
cases and no others. Tillaux 2 also saw a case, of eight days' standing, in a girl 
22 years of age, which he was unable to reduce. Minich, 3 in a case which came 
under his observation, reduced the ulna easily, but did not succeed in reducing 
the radius until he had made several attempts. Minich, in his report of this 
case, refers to three other cases as having been seen by Vignolo, Bardeleben, and 
Chevalier. Poinsot has also reported a case seen by his colleague Arnozan, 
which was accompanied with a fracture of the internal condyle, but which for 
that reason cannot be considered as representing a true dislocation. 

To these cases I will add the case reported by Dr. Erskine Mason as having 
been seen by himself and Dr. Whybrew. The man was 28 years old, and the 
accident had happened in a fall when he was intoxicated. He had supposed it 
was a sprain, and these gentlemen were not consulted until the eighteenth day. 
The character of the dislocation was apparent, but they could not positively 
determine but that a portion of the external condyle had been broken off; there 
was, however, no crepitus. The limb was nearly straight, and would admit of 

1 Michaux, Bullev, Mayer. From Malgaigne, Paris ed., 1855, vol. ii. p. 631. 

2 Tillaux, Gaz. deV Hop., 1877, No. 99. 

3 Minich, Lo Sperimentale, 1880, fas. 6. 



652 DISLOCATIONS OF THE WRIST. 

but slight flexion. Under ether, prolonged efforts at reduction were made, with 
the result of finally reducing the ulna, but the radius remained unreduced. 1 

(b) Transverse. Ulna Inward, and Radius Outward. 

The following case, reported by Warmont, was presented in the service of 
Guersant, 2 at the Hopital des Infants, June 29, 1854 : A boy, 15 years old, had 
fallen a few feet, striking upon the palm of his left hand. The elbow was enor- 
mously swollen ; its transverse diameter was much increased, while the antero- 
posterior seemed flattened. No abnormal protrusion existed in front, but 
externally the head of the radius projected, having ascended along the external 
border of the humerus. The olecranon was displaced inward, so that the inner 
condyle was embraced by the great sigmoid cavity. Between the bones of the 
forearm, thus separated, almost the whole of the articular surface of the humerus 
was lodged. The forearm was semiflexed and semipronated. 

(c) Oblique. Ulna Backward, and Radius Outward. 

Samuel Withe 3 has described the case of a boy, set. 13, who had fallen vio- 
lently upon his left elbow. "The condyles of the humerus protruded through 
the skin at the internal portion of the articulation, exposing entirely the trochlea 
of the humerus ; the ulna was dislocated backward and the radius outward." 
Reduction was easily effected, and a satisfactory result ensued. 

(d) Oblique. Ulna Forward, and Radius Outward. 

Maimer Mons 4 witnessed this dislocation in a man who had struck his elbow 
violently against a wooden obstacle while it was in a position of forced flexion. 
The ulna was displaced forward without fracture of the olecranon, the radius 
was completely displaced outward. Reduction was easily effected by traction 
and pronation. The cure was effected in two months. 



CHAPTEE XI, 

DISLOCATIONS OF THE WRIST (RADIO-CARPAL). 

Regarded as an accident of not unusual occurrence by Hippocrates, 
J. L. Petit, Duverney, Boyer, and by most if not all of the older writers, 
its frequency began to be questioned by Pouteau, and finally its existence 
was almost absolutely denied by Dupuytren, who remarks : 

" I have for a long time publicly taught that fractures of the carpal end of the 
radius are extremely common ; that I had always found those supposed disloca- 
tions of the wrist turn out to be fractures ; and that, in spite of all which has 
been said upon the subject, I have never met with, or heard of, one single well- 
authenticated and convincing case of the dislocation in question." Dupuytren 
subsequently declared that he would not positively deny the possibility of the 

1 Mason and Whybrew, Medical Record, April 10, 1880, p. 397. 

2 Warmont, Rev. Med.-Chir., t. xvi. p. 303. 

3 Withe, A. Cooper, (Euv. Chir., ed. de Chassaignac et Richelot, Paris, 1837. 
* Maimer Mons, Dent. Milit. Z3itschr., 1887, Hft. 8 u. 9, p. 401. 



DISLOCATIONS OF THE WRIST. 653 

accident, yet that " it must at least be admitted that the accident is an extremely- 
rare one." Wishing to explain this infrequency, he says : " In examining the 
structure of the soft parts, one cannot fail to perceive that it is not the ligaments 
which prevent the displacement of the articular surface forward, but that this 
effect is especially due to the multitude of flexor tendons, deprived as they are 
at this point of all the fleshy parts, and reduced to the simple fibrous tissue 
which composes them. These tendons are bound together beneath the anterior 
annular ligament of the wrist, and thus offer so efficient a resistance that severe 
falls are insufficient to tear them through ; the hand is forced into a state of 
extreme extension, and the tendons are firmly applied on the anterior part of 
the radio-carpal articulation. If the extension is still further augmented, the 
wrist-joint is yet more closely clasped by these parts, and their power of resist- 
ance is incalculable ; I am convinced that a force equivalent to one thousand 
pounds weight would be inadequate to overcome it; and the known power of 
the tendo-Achillis is sufficient to prove that this computation is not exaggerated. 
" The risk of dislocation backward by a fall on the dorsal surface of the hand 
is equally precluded by the tendons of the extensor muscles. Their arrange- 
ment and relations at the back of the joint are similar; it is true, they are not 
quite so strong, but we must admit that their power of resistance is very con- 
siderable, when we take into consideration how they are inclosed in sheaths as 
they cross beneath the posterior annular ligament of the wrist. I have not 
alluded to the ulna, for it has really little or nothing to do with these move- 
ments, as -it does not articulate (directly) with the hand. To sum up, then, the 
extreme rarity of dislocation forward or backward is owing to the obstacles 
opposed by the flexor or extensor tendons/' 

The opinion of such a writer as Dupuytren, whose experience was very 
great, and who described only what he had seen, is always entitled to 
profound respect ; yet it has been the practice of nearly all who have 
made any reference to his opinions in this matter to speak of them lightly, 
and not a few have falsely represented him as saying that a dislocation 
was " impossible." The fact is, that surgeons do still constantly mistake 
fractures of the lower end of the radius for dislocations, as my own per- 
sonal observations can attest ; and notwithstanding examples have been 
reported by Rene, Marjorlin, Padieu, Cruveilhier, Voillemier, Poinsot, 
Malgaigne, Scoutetten, Bransby Cooper, Fergusson, W. Parker, and 
others, yet the whole number of cases for which the distinction is claimed 
is, to this day, so inconsiderable as only to establish the value and accu- 
racy of Dupuytren's opinion that the " accident is an extremely rare 
one." But it is, perhaps, most remarkable, that while very few of these 
supposed examples have been permitted to be examined after death, in a 
large majority of the cases in which the autopsy has been made, the dis- 
location has been found to be complicated with a fracture, generally of 
the lower extremity of the radius or of the styloid apophysis of the ulna. 

The existence of a complication, however, does not render the accident 
any the less a dislocation, although it may render the diagnosis more 
difficult, and modify somewhat the indications of treatment. A knowledge 
of the fact, also, that such complications have always been observed in 
the autopsy, may leave us in doubt as to what is the natural history of 
a simple uncomplicated dislocation, if, indeed, it does not warrant a 
suspicion that such a case never occurs. We shall, nevertheless, after a 
careful analysis of the cases as they have been reported, and by a con- 
sideration of the anatomy of this articulation, be able to determine with 
some degree of accuracy, perhaps, what are, or what ought to be, the 
usual causes, signs, treatment, etc., of these accidents. 



654 DISLOCATIONS OF THE WRIST. 

Partial dislocations have also been frequently described by surgeons. 
I have never met with an example, but the following case, related to me 
by the patient himself, I believe to have been a case in point. 

Lewis C, of Buffalo, set. 18, by a fall upon his hand, broke the left forearm 
below the middle, and at the same time, as he affirms, partially dislocated the 
carpal bones backward. Dr. Spaulding, of Williamsville, N. Y., took charge of 
the limb, and pronounced it a fracture, with partial dislocation, and for more 
than a year after the accident the bones had a tendency to become displaced in 
the same direction. Whenever he attempted to lift even the weight of half a 
pound, with his hand supinated and his forearm extended horizontally, the 
lower end of the radius would spring suddenly forward, and all power in the 
arm would be lost. When this happened, as it did quite often, he always 
reduced the bones himself, by simply pushing upon them in the direction of the 
articulation. Fourteen years after the accident, I examined the arm and found 
it in all respects perfect, except that the forearm was shortened about one-third 
of an inch, which shortening was due, no doubt, to the overlapping of the broken 
bones. 

I am unable to verify the accuracy of the statements made in the fol- 
lowing paragraph ; but as there seems to be no reason why they should 
not be accepted, it will be proper to give them a place in this treatise. 

" According to Francis L. Parker, M.D., Professor of Anatomy in the Medical 
College of South Carolina {Trans. S. C. Med. Assoc), there are thirty-three cases 
of so-called dislocations of the wrist-joint on record (omitting the cases of W. 
Parker and Rene), including his own, viz., case of dislocation of the wrist-joint 
backward. Of these, twenty-three are said to have been dislocated backward 
and ten forward ; of this entire number only seven, five backward and two for- 
ward, are free from all objection. Of the twenty-six cases of doubtful or unsatis- 
factory dislocations, sixteen were complicated with fracture of one of the bones 
or processes connected with the joint; three were compound, three were incom- 
plete, two were arthritic or pathological specimens, and two were objected to 
from other causes. Of the thirty-three so-called dislocations, the sex is recorded 
here in fourteen instances ; of these eleven were males and three were females. 
Of the seven cases classed as genuine ones, one post-mortem was made (case of 
M. Malle), which confirmed the diagnosis; in six remaining cases the patients 
regained the use of the limb in a very short time, without a tendency to dis- 
placement or deformity. Of these seven cases accepted as genuine, two back- 
ward dislocations were produced, the force of the fall being received, in one 
instance, on the dorsum of the hand (Hamilton's) ; in the other upon the palmar 
surface (Parker's) ; in M. Malle's case, a forward displacement, the presumption 
is that the patient fell on the palm of his hand, but this is not definitely stated ; 
and in the four remaining cases this point is not specified. He lays down the 
following practical conclusions, which may be derived therefrom: 1st. The 
wrist-joint may be dislocated backward or forward without fracture or a rapture 
of the integuments ; both are extremely rare; the backward displacement is the 
most frequent. 2d. Cases of so-called dislocation of the wrist may be associated 
with fracture of the radius and ulna, or with either of these bones separately, 
with both styloid processes, or either of them, or with fracture of the articu- 
lating surface of the radius ; no instance has been recorded of a dislocation of 
this joint complicated with fracture of the carpal bones. 3d. Dislocation of the 
wrist backward or forward may be complicated with rupture of the integuments 
anteriorly or posteriorly, or laterally, with or without fracture of the styloid 



processes." 1 



1 F. L. Parker, Med. Rec, Nov. 1, 1871. 



DISLOCATIONS OF THE CARPAL BONES BACKWARD. 655 



§ 1. Dislocations of the Carpal Bones Backward. 

Causes. — The same casualty, namely, a fall upon the palm of the 
hand, which, as we have elsewhere noticed, produces frequently a fracture 
of the lower end of the radius, occasionally a dislocation of the radius 
and ulna backward, at the elbow-joint, may also, it is believed, occasion 
sometimes a dislocation of the carpal bones backward. In several of the 
cases reported, this cause has been assigned ; but in the only example of 
simple dislocation which has ever come under my notice, and which I 
have every reason to believe was a simple dislocation unaccompanied with 
a fracture, the carpal bones were thrown back by a fall upon the back of 
the hand. The following is a brief account of the case : 

S. P., set. 75, while walking with his son after dark, and holding in his right 
hand a satchel, slipped and fell. In the effort to save himself, and still retaining 
his grasp upon the satchel, his right hand struck the sidewalk flexed, and in 
such a way that the whole force of the fall was received upon the back of the 
hand and wrist, thus throwing the hand into a state of extreme flexion. In less 
than twenty minutes he was at my house. No swelling had yet occurred, and 
the moment I looked at the wrist I said to him, " You have broken your arm;" 
so much did it resemble a fracture of the lower end of the radius. A further 
examination led me to a different conclusion. The palmar surface of the wrist 
presented an abrupt rising near the radio-carpal articulation, the summit of 
which was on the same plane and continuous with the bones of the forearm, and 
a corresponding elevation existed upon the dorsal surface terminating in the 
carpal bones and hand ; the hand was slightly inclined backward, but the fingers 
were moderately flexed upon the palm. To this extent the accident bore the 
features of a fracture of the radius ; but the hand did not fall to the radial side ; 
the projections upon the palmar and dorsal surfaces were more abrupt than I 
had ever seen in a case of fracture, and which, if it were a fracture, would 
imply that the broken extremities had been driven off from each other com- 
pletely ; the most salient angles of these projections were abrupt, but not sharp 
or ragged ; the styloid apophyses could be distinctly felt, and I was not only 
able to determine that they were not broken, but, by observing their relations to 
the palmar and dorsal eminences, it was easy to see that these latter correspond 
to the situation of the articulation. In addition to these evidences that I had 
to deal with a dislocation, and not a fracture, I had the testimony furnished by 
the reduction, which was not made, however, until by every possible means the 
diagnosis was definitely settled. Seizing the hand of the gentleman with my 
own hand, palm to palm, and making moderate but steady extension in a straight 
line, the bones suddenly resumed their places with the usual sensation or sound 
accompanying reductions. There was no grating, or chafing, or crushing, nor 
was the reduction accomplished gradually, but suddenly. To test still further 
the accuracy of the diagnosis, I now pressed forcibly upon the wrist from before 
back, but without producing any degree of displacement, nor could any crepitus 
still be detected. No splint was applied, and on the following morning Mr. P. 
preached from one of the pulpits in the city, only retaining his arm in a sling. 
Sixteen months after the accident this gentleman again called upon me, and I 
found the arm perfect in all respects, except that it was not quite as strong as 
before ; the lower extremity of the ulna was preternaturally movable, and occa- 
sionally he felt a sudden slipping in the radio-carpal articulation. 

Pathological Anatomy. — In the examples of compound or complicated 
dislocations, which have been exposed by dissections, the posterior and 
lateral ligaments have been found extensively torn, as also frequently 
the anterior ligament, with or without separation of the radial or ulnar 
apophyses : the extensor muscles torn up from the lower part of the fore- 



656 



DISLOCATIONS OF THE WRIST. 



arm and displaced ; the first row of the carpal bones lying underneath 
the tendons, and upon the bones of the forearm, sometimes having been 
carried directly upward, sometimes upward and a little inward, and at 
other times upward and outward ; the arteries and nerves have occa- 
sionally escaped serious injury, but more often they have been displaced, 
bruised, or torn asunder. Such are, briefly, the pathological circum- 
stances which may be supposed to exist, also, in a less or greater degree, 
in nearly all cases of simple dislocations. 



Fig. 411. 



Fig. 412. 





Dislocation of the carpal bones backward. 
(From Fergusson.) 



Dislocation of the carpus backward; 
scaphoid broken and its upper half 
with the semilunar remains in connec- 
tion with the radius. (Pick.) 



[Pick {Fractures and Dislocations) gives an illustration of a backward disloca- 
tion of the carpus with transverse fracture of the scaphoid. (Fig. 412.)] 

In compound dislocations, however, the muscles, or rather the tendons, 
are twisted, torn, and thrust aside, producing very extensive lesions 
among the deeper structures of the forearm and hand before the integu- 
ments can be made to yield. 

S. XL, set. 54, had his right arm caught between the bumpers of two cars, 
bruising the hand and dislocating the carpal bones backward, the radius and 
ulna being thrown forward and pushed completely through the skin into the 
palm of the hand. Most of the flexor tendons had been merely thrust aside, 
but one or two were torn asunder ; the median nerve was torn off, but the radial 
and ulnar nerves were apparently uninjured, and there was no fracture. The 
patient being a temperate man, in perfect health, and the bones having been 
easily replaced by moderate extension, it was determined to make an effort to 
save the arm. The limb was, therefore, laid on a carefully padded splint, and 
cool water lotions diligently applied. Phlegmonous erysipelas began to develop 
itself on the third day ; and on the ninth, gangrene having attacked the limb, I 
amputated a little above the middle of the humerus. On the fourteenth day 
hemorrhage occurred suddenly from the stump, and when I reached him he was 
pulseless and dying. The result demonstrated the error of the attempt to save 
the limb without resection of the lower ends of the bones of the forearm. I 
will also add, that according to my later experience it would have been better, 
if an attempt were to be made to save the hand without resection, to have used 
warm instead of cold water, and when gangrene occurred, to have applied hot 
water, or water at a temperature of 105° or 110° F., either in the form of fomen- 
tation or a bath. 




DISLOCATIONS OF THE CARPAL BONES FORWARD. 657 

Symptoms. — The usual signs have already been sufficiently stated in 
the example which I have given. The most important diagnostic marks 
are found in the abruptness of the 

angles formed by the projecting Fig. 413. 

bones; the relation of these prom- 
inences to the styloid apophyses ; in 
the total absence of crepitus ; and in 
the reduction, which is accomplished 
easily, suddenly, and with a charac- 
teristic sensation. If a fracture 
complicates the accident, Crepitus Dislocation of the carpal bones backward, 
may also be present. It should be 

remembered, moreover, that when the styloid process of the radius is 
broken, if the hand is moved backward and forward this process will 
move also, which might lead to the supposition that the radius was 
broken higher up, and that it was not a dislocation at all. 

Prognosis.— -In compound dislocations the prognosis is exceedingly 
grave, unless the surgeon determines to resort to amputation, or, what 
is generally much preferable, to resection. In dislocations complicated 
with fracture of the posterior edge of the articulating surface of the 
radius ("Barton's fracture'' 1 ), some difficulty may be experienced in 
retaining the bones in place ; but when this fracture does not exist, the 
posterior margin of the articulation, considerably elevated above its ante- 
rior margin, constitutes a sufficient protection against a redislocation in 
that direction. In all cases, also complicated with fracture, even of an 
apophysis, intense inflammation and swelling are likely to follow, and the 
danger of a permanent ankylosis is greatly increased. 

Treatment. — Extension in a straight line has generally been found 
sufficient to accomplish the reduction ; to which may be added a slight 
rocking or lateral motion, if necessary. The reduction may be effected 
also by pressing the hand backward, while the surgeon pushes the carpus 
downward from behind and above, in the direction of the articulation. 
Unless a tendency to displacement exists, no splints or bandages of any 
kind ought to be applied, but the case should be treated by rest and 
fomentations until all danger from inflammation has passed. 

§ 2. Dislocations of the Carpal Bones Forward. 

The causes, mechanism, symptoms, pathology, treatment, etc., of this 
accident resemble those of the preceding dislocation with only the differ- 
ences necessarily due to a change in the direction of the bones. 

Mr. Haydon, of London, reported the following case, 2 which is especially in- 
teresting as furnishing an example of a dislocation of both wrists at the same 
moment, and from similar causes, but in opposite directions. 

A lad, aged about thirteen years, was thrown violently from a horse on the 
11th of June, 1840, striking upon the palms of both hands and upon his fore- 
head. The left carpus was found to be dislocated backward, the radius lying in 

1 Philadelphia Medical Examiner, 1838. 

2 Bransby Cooper's edition of Sir Astley Cooper's work on Fractures and Dislocations. 

42 



i 



658 



DISLOCATIONS OF THE LOWER END OF ULNA. 



front and upon the scaphoides and trapezium. The right carpus was dislocated 
forward, the radius and ulna projecting posteriorly, and the bones of the carpus 
forming an " irregular knotty tumor terminating abruptly " anteriorly. A very 
careful examination was made to determine what parts came in contact with the 
resisting force, but although the palms of both hands were extensively bruised, 
there was not the slightest bruise on the back of either hand. Nor were the 



Fig. 414. 



Fig. 415. 





Dislocation of the carpal bones forward. 



Appearance of a dislocation of the carpus 
forward. 



gentlemen present able to find any evidence whatever that the dislocation was 
accompanied with a fracture. " Moreover," says Mr. Haydon, " we were 
strengthened in our opinion that this was a case of dislocation, unattended with 
any fracture, because the dislocations appeared so perfect ; the two tumors in 
each member so distinct; the reduction so complete; the strength of the parts 
after reduction so great; and lastly, by the very trifling pain felt after reduc- 
tion, for within an hour after, the patient could rotate the hand, and supinate it 
when pronated — this could not, we believe, have been done had there existed a 
fracture." 



CHAPTEE XII. 

DISLOCATIONS OF THE LOWER END OF THE ULNA 
(INFERIOR RADIO-ULNAR). 



In connection with fractures of the lower end of the radius this acci- 
dent is not very uncommon. I have myself met with it under these cir- 
cumstances several times ; but without a fracture of the radius it is quite 
rare. Dupuytren met with but two cases in his long and extensive prac- 
tice. Sir Astley Cooper does not record a single instance, and many 
surgeons affirm that they have never seen the dislocation in question, 
uncomplicated with a fracture of the radius. 



DISLOCATIONS OF LOWER END OF ULNA BACKWARD. 659 



§ 1. Dislocations of the Lower End of the Ulna Backward. 

Malgaigne never met with a case, but he refers to eleven or twelve 
examples which had been reported up to the time he wrote. I have met 
with three cases. 

Causes. — Dugas mentions the case of a little girl in whom the acci- 
dent occurred in both arms, but at different periods, by being lifted by the 
hands. One of the patients seen by Desault, a child five years old, had 
the ulna dislocated backward by extension accompanied with forced pro- 
nation ; and in another example, cited by him, forced pronation alone, as 
in wringing wet clothes, was found to have been sufficient. In Her- 
teaux's case the patient had fallen upon her wrist. 

Pathological Anatomy. — Rupture of the synovial membrane (sacci- 
form ligament), and also rupture of the internal lateral ligament, and of 
the triangular fibro-cartiiage, the little head or lower extremity of the 
ulna abandoning its socket in the radius, and being thrown backward 
or in some cases backward and outward, so as to cross obliquely the lower 
end of the radius ; or it may incline inward as well as backward. 

M. F., set. 27, having puerperal mania, was confined some time in a strait- 
jacket, and the accident happened during this confinement, about six weeks 
before she came under my notice. I found the right ulna displaced backward 
so that its articular surfaces were completely separated ; but it did not override 
the radius and with moderate pressure it was returned to place. The dislocation 
and reduction, which had been frequently made by the house staff since the 
accident, caused no pain, but was accompanied with a slight grating sensation. 

Mrs. M. H. fell upon her left hand. I saw her four weeks after the accident. 
The radius was not broken. The ulna projected backward, and she was unable 
to pronate the forearm. It was easily reduced, but would not remain in place 
without support. She was not under my care, and I am not informed as to the 
treatment or its results. Mr. S., set. 50 years, fell striking upon his hand and 
elbow, causing a fracture of the external condyle of the humerus, and a disloca- 
tion backward of the lower end of the ulna. The dislocation was reduced 
promptly and easily by Dr. Dwyer, of this city, and when I saw the patient on 
the following day, the arm was much swollen, but the ulna had remained in 
place without bandages or other means of support. 

Prognosis. — In recent cases the reduction has generally been accom- 
plished without difficulty, and in only three or four instances has the 
bone become spontaneously displaced. 

Locler reduced the ulna after eight weeks, and Rognetta after sixty days. In. 
one of the examples to which I have already referred as having been seen by 
myself, the dislocation had existed twenty years, the accident having occurred 
in Ireland when the person was fifteen years old. When I examined the arm 
the right ulna projected backward and a little outward, about half an inch. He 
said he had been lame with it for several years, but the motions of the wrist-joint 
were now completely restored, and both pronation and supination were perfect. 

Symptoms. — The hand is usually fixed in a position midway between 
supination and pronation. Boyer, however, found the hand in a state of 
extreme pronation. The extremity of the ulna is felt and seen distinctly 
upon the back of the wrist, prominent and movable ; and the styloid 
process is no longer in a line with the metacarpal bones of the little 
finger : the fingers, hand, and forearm are slightly flexed. 



660 DISLOCATIONS OF THE LOWER END OF ULNA. 

Treatment. — The reduction may be accomplished by holding firmly 
upon the radius and at the same moment pushing the ulna forcibly 
toward its socket; or by simply supinating the hand strongly. Some 
cases demand also extension and counter-extension. Generally the bone 
has been found to remain in its place without assistance, yet in three or 
four of the examples upon record the constant tendency to displacement 
when the pressure was removed has rendered it necessary to employ 
splints and compresses. 

§ 2. Dislocations of the Lower End of the Ulna Forward. 

The dislocation forward is said by Malgaigne to be more rare than the 
dislocation backward. 

In addition to the nine cases collected by him, I have been able to add one 
reported by Parker, of Liverpool, one by R. F. Weir, of New York, 1 and one 
seen by myself. 

While the dislocation backward is usually caused by violent pronation 
of the hand, this dislocation is most often occasioned by violent supina- 
tion. The hand is, therefore, generally found to be supinated forcibly, 
and the projection formed by the end of the bone is seen upon the front 
of the wrist instead of the back. By pushing the ulna toward its socket 
while an attempt is made to flex the hand, or by extension, supination, 
etc., it is made to resume its position readily. In the case reported by 
Parker, however, the reduction was effected only while the hand was 
pronated. 

Parker's case is thus related : J. D., aged 40 years, states that he is a carter, 
and falling down, the shaft of the cart fell upon his arm and forearm in such a 
way as to supinate them forcibly. He complains of pain in the left wrist. The 

Fig. 416. 




Dislocation of lower end of ulna forward. (Case of Wm 



forearm is supinated, and cannot be pronated, the attempt causing much suffer- 
ing. The wrist-joint can be flexed or extended without much pain. On looking 
at the back of the wrist, the appearance is characteristic : the natural prominence 
of the ulna is wanting ; an evident depression exists, as if the lower end of the 

1 Weir, Arch. Clin. Surg., April 15, 1877, p. 10. 



DISLOCATIONS OF THE CARPAL BONES. 661 

ulna had been dissected out ; it can be traced, however, on a plane anterior to 
the radius, its button-like head being distinctly felt under the flexor tendons. 
Several ineffectual and very painful attempts were made to accomplish the 
reduction, by pushing the head of the ulna into its natural situation. This was 
at last effected by seizing the hand to make extension (counter-extension being 
made at the elbow), then forcibly pronating the hand, at the same time pressing 
backward the dislocated head of the bone with the fingers of the left hand. 
After persevering for a short time, the bone was felt to assume its natural position, 
the wrist acquired its usual appearance, and the ordinary movements of the 
joint could be readily performed. There was no tendency to dislocation, and 
the man was dismissed with directions to keep the bone quiet, and to foment it. 
He attended as an out-patient for two or three days, after which, complaining 
of nothing but a little weakness in the part, a bandage was applied, and ordered 
to be worn for a short time. 1 

The following is the case seen by me : Wm. C, set. 27 years, had his left arm 
caught in machinery and "twisted," or rotated violently, causing a simple dis- 
location of the ulna forward. No attempt was made at reduction. He con- 
sulted me several months after the accident occurred, when I found the lower 
end of the ulna projecting on the palmar surface, and inclined toward the radius. 
It could be reduced easily, but would not stay in place ; pronation was lost, but 
all other movements of the arm were preserved. He was a laboring man, and 
declined to have the necessary apparatus applied to secure permanent reduction, 
since it would prevent his immediate return to work. 

Dr. Weir's patient was a woman, set. 49 years, in whom the accident occurred 
by a direct force applied to the back of the ulna near its lower end. She was 
seen within a few minutes by Dr. Weir, the wrist presenting a singular deform- 
ity. It was much narrower than the other, and in place of the usual prominence 
posteriorly, there was a deep depression, and the head of the ulna projected 
slightly in front. The hand was semiflexed and nearly supinated. An attempt 
to reduce the dislocation without an anaesthetic failed ; but under the influence 
of an anaesthetic the reduction was accomplished easily, by direct pressure made 
upon the lower end of the ulna. The recovery of the use of the hand was 
speedy and complete. 

I found in the Long Island College Hospital a girl 13 years old, who, two 
years before, had fallen upon the palm of the right hand causing a dislocation 
of the lower end of the ulna. A doctor applied a splint and kept it on four 
weeks, but when the splint was removed the ulna became displaced as at first. 
When examined by me, the ulna became displaced backward in the act of supi- 
nation, and forward in the act of pronation ; in consequence of which the strength 
of the wrist was considerably impaired. 



CHAPTEE XIII. 

DISLOCATIONS OF THE CAKPAL BONES (AMONG THEMSELVES). 

Bound together on all sides by strong ligaments, and enjoying only a 
very limited degree of motion among themselves, the carpal bones seldom 
become displaced except in gunshot wounds, or in connection with exten- 
sive lacerations and fractures of the neighboring parts. Simple disloca- 
tions, or rather subluxations of these bones, do, however, occasionally 
take place, but, so far as I have been able to ascertain, except in the case 

1 Parker, Amer. Journ. Med. Sci., April, 1843, p. 470, from Lond. and Edin. Month. Journ. 
Med. Sci., Dec. 1842. 



662 DISLOCATIONS OF THE CARPAL BONES. 

of the pisiform, only in one direction, namely, backward. The bones of 
the carpus, which are said occasionally to have suffered simple backward 
subluxation, are the semiulnar, cuneiform, and pisiform of the first row, 
and the trapezium, magnum, and unciform of the second row. 

Magnum. — Richerand, the editor of Boyer's Lectures, says that he 
once met with a subluxation of the os magnum backward, of which he 
has given the following account : 

" Mrs. B., in a labor-pain, seized violently the edge of her mattress, and 
squeezed it forcibly, turning her wrist forward ; she instantly heard a slight 
crack, and felt some pain, to which her other sufferings did not allow her to 
attend. Fifteen days afterward, happily delivered, and recovered by the care 
of Professor Baudelocque, she showed her left hand to this celebrated accoucheur, 
and expressed her disquietude about the tumor which appeared on it, especially 
when much bent. I was called to visit the lady. I found that this hard circum- 
scribed tumor, which disappeared almost totally by extending the hand, was 
formed by the head of theos magnum, luxated backward ; I replaced it entirely 
by extending the hand and making gentle pressure on it. As the affection did 
not impede the motion of the part, as the tumor disappeared on extending the 
hand, and as it would have been but little apparent in any state of the hand had 
Mrs. B. been more in flesh, I advised her not to be uneasy about it, and to apply 
no remedy to it." * 

Bransby Cooper saw the os magnum displaced backward in a stout, muscular 
young man, by a fall upon the back of the hand when in extreme flexion. The 
hand remained slightly bent, and the projection of the os magnum was very distinct. 
Reduction was attempted by extending the whole hand, at the same time making 
pressure upon the displaced bone ; this not succeding, extension was made from 
the middle and forefingers only, while pressure was kept up on the os magnum, 
when suddenly the bone resumed its natural position. On flexing the hand, 
however, the dislocation was immediately reproduced ; and it became necessary 
to apply a compress and splint. For several days after, he was in the habit of 
pushing it out by flexing the hand, in order that the young men at Guy's Hos- 
pital might see its reduction ; which was always easily accomplished by simply 
pushing upon it. 

Magnum and Cuneiform. — Sir Astley says that both the os magnum 
and cuneiform are sometimes thrown a little backward, from simple relax- 
ation of the ligaments, producing a great degree of weakness, so as to 
render the hand useless unless the wrist be supported ; and he mentions 
the case of a young lady in w T hom the os magnus was thus displaced, and 
who was obliged to give up her music in consequence; for when she 
wished to use her hand, she was compelled to wear two short splints, 
made fast to the back and forepart of the hand and forearm. Another 
lady, whose hand was weak from a similar cause, wore, for the purpose 
of giving it strength, a strong steel chain bracelet, clasped very tightly 
around the wrist 2 

Pisiform. — South 3 says that Gras has described a dislocation of the 
pisiform bone, and Fergusson says he has known an example in which 
this .bone was detached from its lower connections by the action of the 
flexor carpi ulnaris. 4 Little benefit, he thinks, can be expected from any 
attempts to keep it in place when it is dislocated, nor is its displacement 

1 Richerand, Boyer's Lectures on Diseases of Bones, Amer. ed., 1805, p. 261. 
• 2 Sir A. Cooper, op. cit., p. 435. 

8 Note to Chelius, by South, op. cit., p. 234. 
4 Fergusson, op. cit , p. 190. 



DISLOCATIONS OF THE METACARPAL BONES. 663 

of much consequence. In case it were dislocated without a rupture of 
the flexor carpi ulnaris, it would necessarily be drawn more or less up- 
ward, in the direction of the tendon and muscle. In children this bone 
moves very freely upon the cuneiform, and even in adults it is quite 
movable, and I have seen a surgeon mistake this natural mobility for a 
partial dislocation. 

Lunare. — Erichsen thinks he has seen a dislocation of the os lunare 
produced by a fall upon the hand when forcibly flexed. By extension 
and pressure it was easily replaced, but when the hand was flexed the 
dislocation was immediately reproduced. 1 Notwithstanding that Sir 
Astley, Miller, and others have taught that the cuneiform bone is liable 
to displacement, and that South has affirmed the same of the unciform, 
I have found no account of an example of simple dislocation of single 
carpal bones except in the cases of the os magnum, pisiformis, and lunare, 
as above mentioned. 

Middle Carpal Articulation. — Maisonneuve has reported an example 
of simple dislocation, without wound of the integuments, at the middle 
carpal articulation. 

A man had fallen forty feet, and was carried dying to l'Hotel Dieu. The 
symptoms were almost precisely those of a dislocation of both rows of the carpal 
bones backward. The reduction was not accomplished during life, but after 
death a simple effort of traction was sufficient to replace the bones. The dis- 
section showed that the bones of the second row were almost completely sepa- 
rated from those of the first ; upon which they were overlapped backward. A 
small fragment of both the scaphoids and cuneiform remained attached to the 
second row, but, with this exception, the separation was complete. 2 Analogous 
cases have been reported by Despres 3 and Richmond. 4 



CHAPTEE XIY. 

DISLOCATIONS OF THE METACARPAL BONES (CARPO- 
METACARPAL ARTICULATIONS). 

§ 1. Dislocations of the Metacarpal Bone of the Thumb Backward. 

Malgaigne has seen two complete dislocations of this bone backward 
upon the trapezium, and he mentions two other cases seen by Michon 
and Bourguet, respectively. 5 Other surgeons have met with similar 
examples. 

Causes. — They have been found to be caused by falls upon the back 
of the distal extremity of the thumb, forcing the metacarpal bone into a 
position of extreme flexion ; and also by blows received upon the end of 

1 Erichsen, Sci. and Art. of Surg., Amer. ed., 1859, p. 259. 

2 Maisonneuve, Malgaigne, op. cit , from Mem. de la Soc. de Chirurg., t. ii. 

3 Despres, Bull, de la Soe. de Chir. de Paris, 28 avril et 4 mai, 1875. 

4 Eichmond, The Lancet, 1879, vol. i. p. 844. Poinsot, op. cit., p. 969. 

5 Malgaigne, op. cit., vol. ii. p. 728. 



664 



DISLOCATIONS OF THE METACAKPAL BONES. 



the thumb, forcing it into an opposite direction. In some cases they 
have been caused by blows received directly upon the articulation. 

Symptoms. — The symptoms are sufficiently clear, although the posi- 
tion of the thumb is not always the same. It has been found perfectly 
straight, without any inclination either way, or flexed more or less, with 
the metacarpal bone also inclined inward toward the palm. The motions 
of the joint are interrupted, and the proximal extremity of the meta- 
carpal bone riding upon the back of the trapezium, projects sensibly in 
this direction, and the trapezium is also felt unusually prominent under 
the thenar eminence. The overlapping varies from a line or two to three- 
quarters of an inch. In the patient mentioned by Bourguet, the head of 
the metacarpal bone almost reached the styloid process of the radius. 

Treatment. — The reduction is to be effected by extension alone, or by 
extension with moderate pressure. In two of the examples reported, 
although the reduction was accomplished very easily, the dislocation was 
reproduced when the extension ceased, and it became necessary to apply 
splints. Malgaigne did not observe, in the case seen by him, any such 
tendency to displacement. In the case of Bourguet's patient the reduc- 
tion was never accomplished, although the attempt was made on the 
second day by a surgeon, and repeated after about two months by Bour- 
guet himself. Fergusson, who has met with several 
Fig. 417. f these dislocations, says that he has seen even a 

splint and roller fail of keeping these bones in place. 

The following is the only example seen by myself: C. 
F., aet. 27, caused an incomplete backward dislocation of 
.."' this bone by striking a man with his clenched fist. It was 

never treated by a surgeon ; and although it always pro- 
jected a little, and the joint was so loose that he could 
1 - easily push it into place, it caused him no inconvenience, 

and after a time the motions became as free as in the 
other thumb. About four weeks before he called upon 
me, and twenty-five years after the first accident, he 
wrenched it again. He was then employed as a stage- 
driver, and was fifty-three years old. The dislocation 
was now complete, and the overriding was about one- 
quarter of an inch. The thumb was nearly straight, the 
line of its axis being nearly parallel with that of the bones 
of the forearm or only slightly flexed. I reduced it easily 
by extension, and applied a gutta-percha splint, but I 
have never seen him since, and do not know the result. 





Case of Peter Golden. 



Incomplete backward dislocations of the meta- 
carpal bone of the thumb seem to be produced by 
the same causes which cause complete dislocations. 
The signs of this accident are sometimes obscure, 
owing to the presence of considerable swelling, and 
they have often been left unreduced. 
In order to the accomplishment of the reduction it will be necessary 
to employ extension, while at the same moment pressure is made directly 
upon the displaced extremity; and to maintain it in place a splint and 
bandage will be required. It is doubtful, however, whether in any case 
the bone can be made to retain so completely its original position as not 
to leave a perceptible deformity. 



DISLOCATIONS OF METACARPAL BONES OF FINGERS. 665 

Peter Golden, get. 16, caused a partial dislocation of this bone backward by 
a blow upon the back of the distal end. Two medical men whom he consulted 
on the first and seventh day after the accident failed to recognize the displace- 
ment. On the thirteenth day he consulted me. The projection of the meta- 
carpal bone was now quite manifest, the swelling having in a great measure 
disappeared. Having secured the accompanying photograph (Fig. 417), he was 
placed under the influence of ether, and the reduction easily accomplished, and 
with a carefully padded splint of gutta-percha, which included a portion of the 
arm, it was retained in place. At the end of six or eight months he was again 
examined by me. The motions of the joint were nearly as free as before, but 
there remained a slight prominence of the metacarpal bone. 

§ 2. Dislocations of the Metacarpal Bone of the Thumb Forward. 

Probably Sir Astley Cooper has reference to an accident of this 
character when he says — speaking of Dislocation of the Head of the 
Metacarpal Bone from the Trapezius — "In the cases which I have seen 
of this accident the metacarpal bone has been thrown inward, between 
the trapezium and the root of the metacarpal bone supporting the fore- 
finger ; it forms a protuberance toward the palm of the hand ; the thumb 
is bent backward, and cannot be brought toward the little finger." 1 Sir 
Astley does not, however, refer to any of the cases which he has seen, and 
Malgaigne says he has not met with such a case, or found one recorded. 
My own experience and observation correspond with that of Malgaigne ; 
although I must confess I have not made it a special purpose to look for 
examples in surgical writings. 

One can never call in question the accuracy of Sir Astley Cooper's 
statements, as to what he professes to have seen, however, and I shall, 
therefore, add what he has said of the mode of reduction. " For the 
facility of reduction, as the flexor muscles are made stronger than the 
extensors, it is best to incline the thumb toward the palm of the hand 
during the time extension is making, and thus the flexors become relaxed 
and their resistance diminished. The extension must be steadily and for 
a considerable time supported, as no sudden violence will effect the reduc- 
tion. If the bone cannot be reduced by simple extension, it is best to 
leave the case to the degree of recovery which nature will in time pro- 
duce, rather than divide the muscles, or run any risk of injuring the 
nerves and bloodvessels." 

Vidal (de Cassis) says he met with an incomplete forward dislocation, 
which he reduced readily, but the patient removed the dressings and the 
dislocation was reproduced, and the bone was not again replaced. 2 

§ 3. Dislocations of the Metacarpal Bones of the Fingers. 

Examples of these accidents are so rare that no attempt will be made 
to establish systematically the causes, symptoms, or treatment. Such 
examples as I have found recorded, or as have come under my own 
observation, will be, however, briefly related. 

1 Sir Astley Cooper's Treatise on Dislocations, and on Fractures of the Joints, 2d London 
ed., 1823, p. 526. 

2 Vidal (de Cassis), Traite de Path. Ext., 3d Paris ed., vol. ii. p. 564. 



666 DISLOCATIONS OF THE METACARPAL BONES. 

Dislocations of the Metacarpal Bones of the Fingers Backward. — 
Roux has recorded one complete dislocation of the second metacarpal 
bone upon the os magnum, caused by an explosion in a mine. It was 
reduced by pressure and extension, but could only be retained in place 
when the hand was flexed. The patient died on the tenth day, and the 
diagnosis was verified by the autopsy. The remaining backward dislo- 
cations of the metacarpal bones of the fingers, and all others that I have 
found recorded, were incomplete, and were generally produced by strik- 
ing with the clenched fist. I will mention a few of several cases which 
have come under my notice. 

S. P., aet. 24, was admitted with a partial dislocation backward of the proximal 
ends of the metacarpal bones of the index and great fingers of the right hand ; 
produced, as he affirms, by striking a man with his clenched fist, about one year 
previously. He says that he called upon a surgeon immediately, but he was 
unable to keep the bones in place. The projection was very manifest at the time 
of my examination, and the hand had never recovered the power of grasping 
bodies firmly. 

During the same year I found in the hospital a precisely similar case, in the 
person of F. McC, set. 32, a sailor, which had occurred four years before, in 
consequence of a blow given with his fist. The same bones were partially dis- 
placed backward, and remained unreduced. This man had also consulted a 
surgeon soon after the injury was received. 

In both of the above examples I instituted a careful examination to determine 
whether it was not the bones of the carpus which were thus displaced ; but the 
result was conclusive as to the nature of the accident, and I have obtained casts 
of both, in order to illustrate partial dislocations of the metacarpal bones. 

In 1866 I met with a similar case, except that the metacarpal bone of the 
index finger was alone dislocated, at Bellevue Hospital, in a woman 28 years of 
age, caused by falling upon her hand with the fingers closed. Eeduction was 
easily effected. 

The following example of dislocation of all the metacarpal bones, except that 
of the thumb, is probably without a parallel. Corporal G., while holding his 
gun at " ready," was hit by a ball on the back and ulnar side of his left hand, 
the ball traversing the back of the hand between the last row of carpal bones 
and the skin, and emerging on the radial side, sending the carpal bones for- 
ward and dislocating the metacarpal bones backward. Great swelling ensued, 
and the nature of the accident was not known for some months. When I ex- 
amined the hand, five years later, the displacement was very conspicuous ; no 
fragments of bone had ever escaped. The motions of all the fingers, except the 
index and little fingers, were unimpaired. 

Dislocations of the Metacarpal Bones of the Fingers Forward. — 

According to Malgaigne, Bourguet met with a forward dislocation of the 
metacarpal bone of the index finger, caused by a great force applied to 
the back of the hand near the carpus. Reduction was effected by exten- 
sion and pressure. With the aid of splints it was retained in place, and 
a cure effected. 

The following case of forward dislocation of the second metacarpal bone at its 
proximal end has been reported to me by J. Marsh, Asst. Surg. U. S. A..: Cor- 
poral Charles C, aet. 25, was struck accidentally on the back of his right hand 
by a hammer weighing seven pounds. The hand was at the time firmly clenched, 
and covered with a buckskin glove. The blow was received obliquely. Dr. 
Marsh saw him half an hour after the accident. A marked depression existed 
on the back of the hand, corresponding to the proximal end of the bone, and 
from this point a gradual elevation of the bone could be traced to its natural 
level at the distal end. On the palm of the hand the displacement was equally 






FIEST PHALANX OF THE THUMB BACKWARD. 



667 



manifest. In this position it was fixed, and seemed immovable. It was easily 
and quickly reduced, however, by making extension from the fingers, while at 
the same moment pressure was made by the thumb in the palm of the hand. It 
returned to its place with the usual sensation accompanying a reduction of a 
dislocation, and the deformity at once disappeared; a ball of tow was now 
placed in the palm of the hand, and secured there by a roller. On the 13th of 
April he returned to duty, but his hand did not acquire its full strength for 
some time longer. 



CHAPTER XV. 

DISLOCATIONS OF THE FIEST PHALANGES OF THE THUMB 
AND FINGERS (METACAEPO-PHALANGEAL). 

(a) Dislocations of the First Phalanx of the Thumb Backward. 

This bone may be dislocated backward or forward, but more frequently 
the dislocation is backward. I have met with the backward dislocation 
ten times. 

[According to Farabeuf, the backward dislocation may be incomplete or com- 
plete. The first is caused by slight dorsal flexion of the phalanx, such as many 



Fig. 418. 




Incomplete dislocation of the thumb. (Farabeuf.) 

persons can voluntarily effect (Figs. 418 and 419) ; the second requires more 
complete dorsal flexion (Figs. 420 and 421). In the former the ligaments are not 



Fig 420. 



Fig. 421. 




imple complete dislocation of the thumb. (Farabeuf.) 



668 OF FIRST PHALANGES OF THUMB AND FINGERS. 



torn, but in the latter the ligaments usually yield, and the round head of the 
metacarpal bone is protruded through the capsule and becomes prominent (Fig. 



Fig. 422. 




Complex dislocation. (Farabeuf.) 
Fig. 423. 




Complex dislocation. (Farabeuf.) 

421). A third or complex form may be produced by extension of a dislocated 
phalanx which then assumes a straight position (Figs. 422 and 423).] 

Causes. — The backward dislocation is occasioned generally by a fall 
or blow upon the distal end and palmar surface of the thumb, causing 
extreme dorsal flexion. 

Pathology. — Surgical writers have recorded a great many cases in 
which it has been found difficult or impossible to effect reduction ; and 
it is asserted upon the authority of Bromfield, quoted by Hey, that the 
extending force has been increased to such an amount as to tear off the 
last phalanx without having succeeded in reducing the first ; but while 
surgeons have united in their testimony as to the exceeding obstinacy of 
a large proportion of these dislocations, they are far from being agreed 
as to the source of the difficulty. 

Sir Astley Cooper finds a sufficient explanation in the six short and powerful 
muscles which are inserted into the first and last phalanges, and especially 
in the flexors. 1 Hey believes the resistance to be in the lateral ligaments, 
between which the lower end of the metacarpal bone escapes and becomes im- 
prisoned. Ballingall, Malgaigne, Erichsen, and Vidal (de Cassis) think the 
metacarpal bone is locked between the two heads of the flexor brevis, or rather 
between the opposing sets of muscles which centre in the sesamoid bones, as a 
button is fastened into a button-hole. Pailloux, Lawrie, Michel, Leva, Blechy, 
Roser, and Hueter affirm that the anterior ligament, including a portion of the 
capsule, being torn from one of its attachments, falls between the joint surfaces 
and interposes an effectual obstacle to reduction. A case of compound disloca- 

1 Lawrie, of Glasgow, says that Sir Astley, in a conversation with him, declared that the 
" sesamoid bones " were the sources of the difficulty. See Amer. Journ. Med. Sci., vol. xxii. 
p. 230, with observations and experiments by Lawrie. 



FIRST PHALANX OF THE THUMB BACKWARD 



669 



tion is recorded, in which. Esmarch saw the capsule in this position, and button- 
holed upon the distal end of the metacarpal bone. 1 Dupuytren ascribes the 
difficulty to the altered relations of the lateral ligaments, which are naturally 
parallel to the axis of the metacarpal bone, but which are now placed at a right 
angle; to the spasm of the muscles, and to the shortness of the member, in con- 
sequence of which the force of extension has to be applied very near to the seat 
of the dislocation. Lisfranc found in an ancient dislocation the tendon of the 




Clove-hitch.. 



Sir Astley Cooper's method of reducing dislocations of 
the thumb, with pulleys. 



long flexor so displaced inward and entangled behind the extremity of the bone 
as to prevent reduction. Esmarch met with a similar case, in which he opened 
the joint and replaced the tendon with a satisfactory result. 2 Deville discovered 
in an autopsy a similar displacement of this tendon outward. Wadsworth has 
made the same observation. 3 

[In complete dislocation the head of the metacarpal bone is forced between 
the two heads of the flexor brevis pollicis (Fig. 426). The tendons of these two 
heads contain the sesamoid bones, to which are attached, also, 1, the abductor 

Ftg. 426. 




The head of the metacarpal bone forced forward between the two heads of the 
flexor brevis pollicis, which tightly embrace its neck. (Fabbin.) 

muscle to the external sesamoid, and 2, the adductor muscle to the internal 
sesamoid. By the interlacement of the fibres of the tendons of these muscles a 
capsule is formed for the palmar surface of the joint. To effectually relax these 
muscles the end of the metacarpal bone must be firmly pressed into the palm.] 



1 Esmarch, Berliner klinische Wochensch., 1876, No. 44. 

2 Ibid. 3 Wadsworth, Am. Med. Times, Feb. 13, 1864, p. 77. 



670 OF FIKST PHALANGES OF THUMB AND FINGERS. 

Symptoms. — I have found the two phalanges in the same axis with 
the metacarpal bone at least twice ; that is, neither flexed nor tilted 
backward ; but in most of the cases the first phalanx inclines backward 
upon the metacarpal bone, and the second phalanx is flexed upon the 
first. 

Prognosis. — The reduction is sometimes, in .recent cases, accomplished 
with great ease. 

A servant girl, set. 25, fell down a flight of steps, striking upon the inside of 
her right hand and thumb. When I saw her, only a few minutes afterward, I 
found the first phalanx standing back almost at a right angle with the meta- 
carpal bone, and the second phalanx also flexed to a right angle with the first ; 
the reduction was effected in about twenty seconds, by bending the first phalanx 
further back, and at the same moment pressing the proximal end of this 
phalanx forward in the direction of the joint. Without employing great force, 
the reduction took place suddenly and with a snap. Very little swelling fol- 
lowed, and in three weeks she was able to use her needle without inconvenience. 

M. W., set. 35, fell from a height, causing a fracture of his left arm, and a 
dislocation of his right thumb backward. I saw him within two hours after 
the accident. The thumb was much swollen, and its position the same as in 
the case just described. Although W. was a strong, muscular man, the reduc- 
tion was accomplished 'in a few seconds by applying over the last phalanx the 
Indian toy called a " puzzle," and making extension in a straight line, while an 
assistant made counter-extension from the hand and wrist. The use of the joint 
was soon completely restored. 

Examples, however, are constantly occurring which are only reduced 
after long-continued and painful efforts, or which, indeed, completely ex- 
haust the patience and baffle the skill of the most experienced surgeons. 

Mary J. S., set. 23, fell upon her right hand with her fingers and thumb 
extended and dislocated this bone backward. A young surgeon attempted to 
reduce the dislocation half an hour after the accident, by the same manoeuvre 
adopted by myself successfully in the case of the servant girl, only that he made 
extension upon the last phalanx at the same moment. The surgeon believes 
that the bone was reduced, but one week later he found it displaced, and, as he 
believes, reduced it again. The same thing occurred a third time. Six months 
after this, the girl consulted me to ascertain what could be done for her relief. 
The thumb occupied the usual position, and admitted of no motion except at the 
carpo-metacarpal articulation. 

In May, 1848, having been called to see G. EL, who had attempted suicide by 
cutting his throat, my attention was arrested by the appearance of his left 
thumb, which I found to be occasioned by an ancient dislocation of the first 
phalanx backward. The accident had occurred, he afterward told me, twelve 
years before, in consequence of a fall while wrestling. A very respectable country 
surgeon was called, and made three several attempts to reduce it, but failed. 
The several bones of the thumb occupied their usual positions, that is to say, the 
positions which they usually occupy in this dislocation, yet notwithstanding the 
almost complete ankylosis of the phalangeal articulations, and the awkward 
encroachment of the distal end of the metacarpal bone upon the palm, the hand 
was quite useful. 

C. E. was brought to me, having a dislocation of the first phalanx of the right 
hand, which had already existed some days, and upon which several unsuc- 
cessful attempts at reduction had been made. The dislocation was backward, 
but the phalanges, instead of standing at an acute or right angle with each 
other and with the metacarpal bone, as is usually the case, were in a straight 
line with each other and parallel with the metacarpal bone. Whether this 
phenomenon existed from the first, or was due to the efforts already made at 
reduction, I could not determine, but the same thing has been noticed occa- 
sionally by other surgeons. The first phalanx, moreover, instead of being placed 



FIRST PHALANX OF THE THUMB BACKWARD. 671 

directly behind the metacarpal bone, occupied a position upon its back a little 
to the radial side of the centre. During quite half an hour I made continued 
and varied attempts to reduce the bone, by extension, by forced dorsal flexion, 
and by pressing the upper end of the first phalanx in the direction of the joint 
while pressure was made against its lower end so as to bring it into dorsal 
flexion, and finally by calling to my aid the "puzzle" and chloroform, but all 
to no purpose. One week later I repeated these efforts, and with no better suc- 
cess. The parents peremptorily refused to allow me to cut the lateral ligaments, 
or flexor tendons, so the bone remains unreduced. 

Treatment. — The modes of reduction practised and recommended by 
surgeons are as diversified and irreconcilable as their views of the mech- 
anism and pathological anatomy of the accident. Sir Astley Cooper 
recommends that extension shall be made by bending the thumb toward 
the palm of the hand, to relax the flexor muscles as much as possible, 
and then, by fastening a clove-hitch upon the first phalanx, previously 
covered with a piece of soft leather, the extension is to be continued, only 
inclining the, thumb a little inward toward the palm of the hand. If 
these means fail after having been continued a considerable length of 
time, he advises that a weight shall be suspended to the thumb, passing- 
over a pulley. Finally, in the event of the failure of this method also, 
Sir Astley thought that no further attempt should be made, and espe- 
cially that no operation for the division of these parts is justifiable. 

Charles Bell proposed flexing the joint, employing at the same time 
pressure ; and in obstinate cases he advised subcutaneous section of the 
lateral ligaments with a small knife, a method which has since been prac- 
tised successfully by Liston, Reinhardt, Gibson, of Philadelphia, Parker, 
of New York, myself, and others. Syme and Lizars justify the practice 
in certain cases. In one case which has come under my notice, after 
failing to effect reduction by the usual methods, I succeeded promptly 
after cutting one lateral' ligament ; and in the second case I only suc- 
ceeded after cutting both lateral ligaments. 

Roser, from his experiments upon the cadaver, concludes that the dis- 
located phalanx must first be bent forcibly backward, or into the position 
termed by some writers dorsal flexion, so as to throw the head of the 
phalanx forward upon the articulating surface of the metacarpal bone. 

Vidal (de Cassis) recommends also that the extension should be made 
first backward, so as to increase the displacement of the first phalanx 
in this direction, and to throw forward its articular surface in the direc- 
tion of the articular surface of the metacarpal bone. Hueter believes 
that if this method fails, when combined with some rotation and lateral 
motion, no other is likely to succeed, and he then advises resection. He 
has, however, himself in all cases been able to effect reduction, but the 
difficulty has been to maintain it, owing to the interposition of the cap- 
sule ; and in such cases he has reduced the dislocation and then applied 
a plaster bandage, grasping the splint and thumb w r ith his hand until the 
plaster was hard, and leaving it undisturbed for fourteen days, at the 
end of which time he- has found that the bones would remain in place 
without the aid of the splint. He believes that the interposed ligament 
has been in the meanwhile absorbed. To me it seems quite certain that 
with the capsule thus interposed, permanent ankylosis must be the final 
result, even though it might be possible to retain the dislocated surfaces 
in apposition, and that resection would be preferable. 



672 OF FIRST PHALANGES OF THUMB AND FINGERS. 

Dorsal flexion as the first and most essential part of the manoeuvre, 
seems to have met with more general approval than any other, and the 
following observations, made by the late Reuben D. Mussey, of Cincin- 
nati, illustrate the general practice among American surgeons at this day : 

"I tilt the dislocated phalanx up until it stands upon its articulating end, place 
both forefingers so as to hold it in that position, and at the same time press against 
the distal extremity of the metacarpal bone, make firm pressure with the thumbs 
against the base of the dislocated phalanx, and slide it into its place, which can 
generally be accomplished with ease. More than twenty-five years ago, the chair- 
man of this committee, from attention to the mechanism of the metacarpopha- 
langeal joint of the thumb, convinced himself that the principal impediment to the 
reduction of the first phalanx from backward displacement is the short flexor of 
the thumb, between the two portions of which (lying close together where they are 
fastened to the sesamoid bones) the head of the metacarpal bone has been thrust, 
the contracted part or neck of this bone lying firmly grasped by them. Fifteen 
years ago, a case occurred of this dislocation which he could not reduce in the 
ordinary way. A subcutaneous division of one of the heads of this muscle was 
made with an iris knife, and the reduction was accomplished with the greatest 
ease. Last year another case occurred, in which we failed of reduction by Dr. 
Crosby's method, which we believe to be the best, and the subcutaneous division 
of both heads of the muscle was made, and the reduction instantly effected." l 

Dr. J. P. Batchelder, of New York, in a paper read before the New York 
Medical Association in 1856, says : " The surgeon should take the metacarpal 
portion of the dislocated thumb between the thumb and finger of one hand, and 
flex or force it as far as may be into the palm of the hand, for the purpose of 
relaxing the muscles connected with the proximal end of the phalanx, particu- 
larly the flexor brevis pollicis. He should then apply the end of the thumb of 
his hand against the displaced extremity of the dislocated phalanx, for the pur- 
pose of forcing it downward, and at the same time grasp the displaced thumb with 
his other hand, and move it forcibly backward and forward, as in strongly forced 
flexion and extension, the pressure against the upper extremity of the first pha- 
lanx being kept up. In this way the dislocated bone may be made to descend, 
so as to be almost or quite on a line with the articulating surface of the meta- 
carpal bone, when the thumb may be forcibly flexed, and, if it be not reduced, 
as forcibly extended, and brought backward to a right angle with the metacarpal 
bone ; when, if the downward pressure, with the thumb placed as before, directed 
for that purpose, has been continued (which thumb, by maintaining its position, 
acts as a fulcrum, as well as by its pressure), the bone will slip into its place, 
and the reduction be effected in less time than has been spent in describing the 
process." 2 

[The very thoughtful and judicious opinions here given are in full accord with 
the most recent writers on this subject. Dorsal flexion is the initial step in the 
procedure; then press the end of the metacarpal bone into the palm; finally, 
crowd the proximal end of the phalanx over the end of the metatarsal bone 
while extending the phalanx. This method should always be pursued, even in 
the third form, where the axis of the phalanx is the same as the metacarpal bone. 
Simple extension of the phalanx, as is often practised, and sometimes with 
powerful apparatus, is contrary to every indication, and is usually unsuccessful.] 

By those who have regarded extension as an important element in the 
reduction, various instruments have been devised for the purpose of ob- 
taining a secure hold upon the dislocated member. Sir Astley Cooper, 
as we have already seen, recommended the sailor's clove-hitch ; 3 Lawrie 
advises that the thumb shall be thrust into the open handle of a large 
door-key ; 4 Charriere and Luer, of Paris, have each invented forceps, so 

1 Mussey, Trans. Amer. Med. Assoc, vol. iii. p. 357, 1850. 

2 Batchelder, ISTew York Journ. Med., May, 1856, p. 340. 

3 Op. eit. 561 ; also Boston Med. and Surg. Journ.. Oct. 1, 1857. 

4 Lawrie, Amer. Journ. Med. Sci., vol. xxii. p. 229 



FIRST PHALANX OF THE THUMB FORWARD. 



673 



constructed with the fenestra and straps that when the blades are closed 
the member is held very firmly in its grasp. Richard J. Levis, of Phila- 
delphia, recommends " a thin strip of hard wood, about ten inches in 
length, and one inch, or rather more, in width. One end of the piece is 
perforated with six or eight holes. The opposite end is partly cut away, 
forming a projecting pin, and leaving a shoulder on each side of it. 
Toward this end of the strip, a sort of handle shape is given to it, so as 
to insure a secure grasp to the operator. Two pieces of strong tape or 
other material, about one yard in length, are prepared. One of these 

Fig. 427. 




Levis's instrument for reduction of dislocations of fingers or the thumb. 

is passed through the holes at the ends of the strip, leaving a loop on one 
side. The other tape is passed through another pair of holes, according 
as it may be a thumb or a finger to which it is to be applied, or varied 
to suit the length of the finger, leaving a similar loop. If a dislocated 
thumb is to be acted on, the second tape should be passed through the 
holes nearest the first. The ends of each separate tape are then tied 
together. To apply this apparatus, the finger is passed through the loops. 
The loop nearest the first joint is then tightened by drawing on the tape, 
which is then brought along the strip to the opposite end, across one of 



Fig. 428. 




s instrument applied to the first finger. 



the shoulders, and secured by winding it firmly around the projecting pin. 
The other tape is tightened in a like manner, crossing the other shoulder, 
and winding around the pin in an opposite direction, when, for security, 
the ends of the tapes are finally tied together. 1 This apparatus enables 
the operator to apply both extension and flexion or leverage in any direc- 
tion. The proximal end of the phalanx may be lifted, or even rotated so 
as to allow one side of the bone to approach the socket before the other. 
I have described 2 an instrument, or rather a toy, in my possession, 
which I suggested might be useful for the purpose of making extension 
upon dislocated fingers ; and which, as will be seen by a reference to one 
of the cases already reported in this chapter, I have since applied suc- 
cessfully. It is made by the Indians, and may always be obtained during 



i 



Levis, Amer. Journ. Med. Sci., Jan. 1857, p. 62. 

43 



2 Buffalo Med. Journ., 1847. 



674 OF FIRST PHALANGES OF THUMB AND FINGERS. 

the watering season, at the Indian toy-shops at Niagara Falls. The In- 
dians call it a "puzzle," and know no other use for it than to fasten it 
upon the thumb or finger of some victim, and then pull him about until 
he begs to be released. The "puzzle" is an elongated cone of about 
sixteen or eighteen inches in length, made of ash splittings, and braided; 
the open end of the cone being about three-fourths of an inch in diame- 
ter, and the opposite end terminating in a braided cord. When applied 

Fig. 429. 




Indian "puzzle," employed for the reduction of dislocations in small joints. 

to the finger, it is slipped on lightly, forming a cap to the extremity, and 
to half the length of the finger, but on traction being made from the oppo- 
site end, it fasten itself to the limb with an uncompromising grasp. If 
constructed of appropriate size and of suitable materials, it becomes the 
more securely fastened in proportion as the extension is increased ; yet 
applying itself equally to all the surfaces, it inflicts the least possible pain 
and injury upon the limb. When we wish to remove it, we have only to 
cease pulling, and it drops off spontaneously. 

Finally, in some compound dislocations it would be better not to 
attempt the reduction of the dislocation until resection has been prac- 
tised. Samuel Cooper relates a case in which the reduction was followed 
by inflammation and death within a week after the accident, and Norris, 
of Philadelphia, mentions an instance which came under his observation, 
where violent inflammation and tetanus followed the reduction. 1 Roux, 
Evans, Wardrop, Gooch, Sir Astley Cooper, and many other surgeons, 
have practised resection successfully in these accidents, and have added 
their testimony in favor of this mode of procedure. 

[It should not be forgotten in using apparatus for extension, that dorsal flexion 
is the position during extension most likely to secure reduction.] 

(b) Dislocations of the First Phalanx of the Thumb Forward. 

Up to the present moment, I have met with but two examples of this 
dislocation, while the backward dislocation has been seen by me ten times. 

H. K., of Eochester, N. Y., set. 24, dislocated the first phalanx of the right 
thumb forward, by striking a man with his clenched fist ; the force of the blow 
being received upon the back of the second joint of the thumb. The dislocation 
had existed three days, and in the meanwhile several attempts had been made 
to reduce the bone by simple extension. The first phalanx was in front of the 
metacarpal bone, and in the same plane; but the last phalanx was slightly 
inclined backward. The hand was already swollen and quite painful. Seizing 
the dislocated thumb in the palm of my right hand, with my fingers resting 

1 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 16. 



PHALANGES OF THE THUMB AND FINGERS. 675 

upon the back of the patient's hand, I forced the two phalanges into flexion by 
firm and steady pressure continued for a few seconds, when suddenly the bones 
resumed their places, and all deformity disappeared. Intense inflammation 
resulted, followed, after a few days, by suppuration under the palmar fascia; 
and in the end the thumb was almost completely ankylosed. 1 

J. M. B., set. 19, called at my office, having a dislocation forward of the first 
phalanx, occasioned, about half an hour before, by being thrown from a horse. 
The last two phalanges were neither flexed nor extended, but. straight, and 
parallel with the metacarpal bone. By the same manoeuvre adopted in the 
preceding case, but with only very moderate force, the dislocation was promptly 
reduced. 

Causes. — The usual causes of this accident are falls *or blows upon the 
thumb while it is flexed ; Lombard has seen it produced by a fall upon 
the palmar surface of the thumb. 

Symptoms. — The symptoms which characterize it are, in general, such 
as we have seen in the two examples which have just been given. The 
metacarpal bone projects posteriorly, and the first phalanx produces a 
corresponding projection toward the palm ; the two phalanges are extended 
upon each other, and parallel with the metacarpal bones. Nelaton saw 
a case in which the first phalanx was flexed about 45° ; and in several 
examples it has been observed to be slightly rotated inward. 

Treatment. — In the few examples of this accident which have been 
reported, the reduction was easily accomplished ; or, at least, I may say 
that the difficulties in the way of reduction were not so great as they are 
usually found to be in dislocations backward. Malgaigne has been able 
to collect but four undoubted examples, all of which were reduced ; 
Lenoir was able to effect the reduction by moderate measures, after the 
bone had been dislocated thirty-eight days. Ward succeeded by simple 
extension. 2 Lombard, after the trial of other plans, finally succeeded by 
reversing the phalanx, employing, as I have before termed it, "dorsal 
flexion," with extension and lateral motion; but in all, or nearly all, 
the other examples the reduction has been effected by flexing the thumb 
forcibly toward the palm — the reverse of the method which we have seen 
preferred, especially by American surgeons, in dislocations backward. 
My own experience, also, authorizes me to recommend this plan. 

(c) Lateral Dislocation of the Last Phalanx. 

[A gentleman struck the inner side of the last phalanx of the right 
thumb violently against the edge of a door. The result was a lateral 
dislocation of the proximal end of the last phalanx, inward, half the 
width of the articular surface. The skin was broken on the inner surface, 
but the joint was not opened. The reduction was readily effected by 
simple extension.] 

(d) Dislocations of the First Phalanx of the Fingers. 

The index and little fingers, owing to their exposed situation, are most 
liable to these dislocations. I have met with three examples of traumatic 

1 Trans. N. Y. State Med. Soc, 1865, p. 73. 

2 Ward, New York Med. Times, Sept. 8, 1860. 



676 



PHALANGES OF THE THUMB AND FINGERS. 



dislocations of these joints, one of which was a forward and two were 
backward dislocations, and all had occurred in the index finger. 

J. N., set. 11, dislocated the index finger of the right hand backward by a fall 
down a flight of stairs. On the same day I found the finger neither flexed nor 
extended, but straight and immovable. The projections occasioned by the ends 
of the two bones were very marked, and such as to render an error in the diag- 
nosis impossible. Eeduction was accomplished with great ease by reversing the 




Backward dislocation of first phalanx. Reduction by extension. 

finger and employing moderate extension, while at the same time the proximal 
extremity of the first phalanx was pushed toward the distal end of the metacar- 
pal bone. In short, the process was the same as that which I have recommended 
in dislocations of the thumb backward. 

In a woman, 35 years of age, the dislocation was caused by her husband hav- 
ing pulled the finger violently backward. The metacarpal bone was thrust 
through the skin on the palm of the hand. Four weeks had now elapsed, and 
the wound had healed. A few days before, the house surgeon had placed her 
under the influence of ether and had attempted reduction, but had failed, and 
she refused to allow me to repeat the attempt. 

In the example of dislocation forward, occasioned by a blow from a 
hard ball, received upon the end of the finger, the first phalanx was in a 
position of extreme extension, and the second moderately flexed. Re- 
duction was effected with great ease by extension in a straight line. But 
if the surgeon were to experience difficulty in the reduction, it would, no 
doubt, be advisable to resort to the method of extreme flexion. In one 
instance, I have seen nearly all the fingers of the left hand, and the 
thumb of the right, dislocated backward by the contraction of the cica- 
trix after a severe burn. 



CHAPTER XVI. 



DISLOCATIONS OF THE SECOND PHALANX OF THE THUMB 
AND THE SECOND AND THIRD PHALANGES OF THE FINGERS. 

Notwithstanding slight differences in the form of the articulations 
between the thumb and fingers, and in the size and situation of the bones 
which compose the phalanges of the fingers, I am disposed, contrary to 
the practice of some other writers upon this subject, to consider all the 



SECOND PHALANX OF THUMB. 



677 



dislocations to which these several joints are liable, under one section. 
Nor, indeed, after the attention which I have given to the dislocations 
at the metacarpophalangeal articulations, do I find much to add in rela- 
tion to these accidents ; since in almost every point of view in which 
they may be considered, they have so much in common. The last pha- 
lanx of the thumb is, of all the phalanges, most liable to dislocation, and 
this generally takes place backward. Very frequently, also, it is accom- 
panied with such a laceration as to render it compound. The dislocated 
phalanx is usually reversed in the backward dislocation, and straight, or 
nearly so, in the forward dislocation. In most cases reduction may be 
accomplished easily by forced dorsal flexion in the case of the backward 
dislocation, and by forced palmar flexion in the case of the forward dis- 
location. 

A young man was brought to my clinic who had met with a forward subluxa- 
tion of this phalanx about one month before. He had fallen upon the end of 
his thumb, and as the accident was followed by a good deal of inflammation and 
swelling, he did not notice the displacement until some time afterward. The 
proximal end of the last phalanx projected two or three lines toward the palm ; 
the finger was straight, and this joint ankylosed. I did not think the chance of 
restoring and maintaining the bone in position sufficient to warrant any inter- 
ference, and he was dismissed with an assurance that after a few months it would 
occasion him no great inconvenience. 



Fig. 431. 




Dislocation of the second phalanx backward. 



T. B., aged about 22 years, by a fall dislocated the second phalanx of the 
middle finger of the right hand backward. The force of the concussion was 
received upon the extremity of the finger. Nine hours after the accident I 
found the bones unreduced ; the finger nearly straight, or with only slight flexion 
of the second phalanx upon the first; the third phalanx forcibly straightened 
upon the second ; all the joints rigid ; finger very painful and somewhat swollen. 
By moderate extension alone, applied for a few seconds, the reduction was ac- 
complished. 

Fig. 432. 




Dislocation of the second phalanx forward. 



J. C, set. 23, came to me to obtain counsel in relation to his finger, which had 
been dislocated the day before, but which he had himself reduced by simple 
extension made in a straight line. His own account of it was, that he fell upon 
a slippery sidewalk, striking upon the end of his ring finger in such a way that 



678 DISLOCATIONS OF THE THIGH. 

it seemed to double under him. On examination he found the second bone dis- 
located inward, or to the ulnar side, completely, the end of the first phalanx 
forming a broad projection upon the opposite side; the last two phalanges fell 
over toward the middle finger, but they were neither flexed nor extended. Seiz- 
ing upon the end of the finger with his right hand and pulling forcibly, he 
promptly reduced the dislocation himself. The bones were now completely in 
place, bat the joints were swollen, tender, and quite stiff. 

Dislocation of the last phalanx is frequently occasioned in the game 
of base-ball, by the ball being received upon the extremity of the finger. 

A private pupil of mine in attempting to catch a very hard ball, received it 
upon the extremity of the middle finger of the left hand, dislocating the last 
phalanx forward. Twenty minutes after the accident I found the distal extremity 
of the second phalanx projecting backward through the skin, the tendon of the 
extensor muscle being torn completely off from its point of attachment to the 
last phalanx. The last phalanx was in a position of slight dorsal flexion, or 
extreme extension. Seizing upon the extremity of the finger, I attempted to 
reduce the dislocation by direct traction, aided by pressure upon the exposed end 
of the second phalanx, but I was unable to succeed until I brought the last 
phalanx into a position of palmar flexion. A slight disposition to redislocation 
was manifested, and a gutta-percha splint was therefore applied ; and, to prevent 
inflammation, the young man was directed to keep it moistened with cool-water 
lotions. Only a moderate amount of inflammation followed, and in a few weeks 
the cure was complete. 

Such accidents, attended with laceration of the integuments, may 
occasionally demand amputation, or at least resection of the projecting 
bone ; but I think Mr. Miller is scarcely right when he says that com- 
pound dislocations of the fingers almost always are of such severity as to 
demand amputation. I have myself met with three other cases which 
were reduced and did well. In one case of simple dislocation of the last 
phalanx of the thumb backward I have been obliged to resort to section 
of the lateral ligaments before accomplishing the reduction. 

This was in a woman admitted to Bellevue Hospital. The accident had hap- 
pened seven days before, by falling and striking upon the end of the thumb. 
The position of the last phalanx was extended, that is, in a line with the axis of 
the first phalanx. She said, however, that it was at first "bent straight back," 
but that a man took hold of it and pulled it out. Having placed her under the 
influence of ether, I attempted reduction by forced backward flexion, but failed. 
I then cut the lateral ligaments by subcutaneous incision, and the reduction was 
accomplished with great ease. 



CHAPTER XVII. 

DISLOCATIONS OF THE THIGH (COXO-FEMORAL). 

The femur is especially liable to dislocation in four directions, namely, 
upward and backward upon the dorsum ilii, upward and backward into 
the ischiatic notch, downward and forward into the foramen thyroideum, 
and upward and forward upon the pubes. Dislocations are occasionally 
met with which cannot be arranged properly under either of these divi- 



UPWARD AND BACKWARD ON THE DORSUM ILII. 679 

sions ; indeed, it is scarcely necessary to say that the head of the bone 
may be thrown in almost every direction from its socket, upward, down- 
ward, inward, and outward, or in either of the diagonals between these 
lines ; and that while in a vast majority of cases it will assume one of 
the positions first named, it may in a few exceptional examples fall short 
of, or much exceed, the limits assigned in this division. Thus, I shall 
have occasion hereafter to mention examples of dislocation directly up- 
ward, in which the head of the bone will be found resting upon the fossa 
between the upper margin of the acetabulum and the anterior inferior 
spinous process of the ilium ; or still higher, between the anterior supe- 
rior and the anterior inferior spinous processes ; or a little to the one side 
or to the other of these points. Examples will be shown of dislocations 
directly downward, in which the head of the femur will rest upon the 
notch between the lower margin of the acetabulum and the tuber ischii ; 
or still lower, and actually below the tuberosity ; or downward and back- 
ward below the spine of the ischium, into the lower or lesser sacro-sciatic 
notch. The head may be thrust across the foramen thyroideum, and be 
only arrested in the perineum upon the ramus, or even beyond the ramus 
of the ischium and pubes ; it may lodge upon the anterior surface of the 
body of the pubes, as well as upon its superior edge ; it may rest against 
the posterior margin of the acetabulum, instead of rising upon the dor- 
sum ; or it may only mount upon its margin, in either of the directions 
named. 

In regard to frequency, the four principal dislocations occur in the 
order in which I have mentioned them ; thus, of 104 dislocations of the 
hip which I have taken the pains to collate, excluding the anomalous or 
extraordinary dislocations, 00 were upon the dorsum ilii, 28 into the 
great ischiatic notch, 13 upon the foramen thyroideum, and 8 upon the 
pubes. 

Chelius and Samuel Cooper have, however, reversed the order of the last two 
varieties, arranging dislocations upon the pubes, in the order of frequency, 
before dislocations into the foramen thyroideum. 

Coxo-femoral dislocations may occur at any period of life. 

A case 1 of thyroid dislocation is reported which occurred in a child six months 
old. One example is mentioned 2 of a recent dislocation upon the dorsum ilii in 
a child eighteen months old. 3 Dr. N. Fanning, of Catskill, N. Y., informs me 
in a letter dated June 25, 1867, that he has reduced a dislocation upon the dor- 
sum ilii, on the tenth day, in a little girl eighteen months old. Mr. Kirby has 
reported a case of recent dislocation in the same direction, in a child of three 
years, 4 and Dr. Buchanan has seen another, at the same age, in a little girl ; the 
dislocation being into the ischiatic notch. 5 Mr. Image communicated to the 
Suffolk branch of the Provincial Medical and Surgical Association the case of a 
boy, three and a half years old, with a dislocation upon the dorsum ilii. It had 
existed twelve days when he was admitted to the Suffolk Hospital. Mr. Image, 
in reporting this case to the Society, remarked that he had been induced to lay 
it before them "in consequence of a charge having been urged against a neigh- 
boring surgeon of pretending to reduce a dislocation of the femur in the dorsum 

1 London Lancet, May 16, ] 868.' "" 2 Gazette Medical. 

3 New York Journ. Med., ISTov. 1850, p. 416. 

4 Amer. Journ. Med. Sci., Jan. 1843 and Jan. 1847. 

5 London Med.-Chir. Eev., Dec. 1828, p. 251. 



680 DISLOCATIONS OF THE THIGH. 

ilii, in a child only four years old, that child being a pauper and chargeable to 
the parish. It was agreed and proved by authorities that no such case was 
recorded, and therefore had not occurred, and that seven years old was the 
earliest period at which this accident had taken place." 1 Litten, of Austin, 
Texas, reports a case of dislocation upon the dorsum ilii in a girl four years old, 
which he reduced by manipulation. 2 Gibney, of New York, has reported a case 
in a boy of four years, which he reduced after six weeks. 3 Dr. Thompson, of 
Onondaga, N. Y., has reported another case in an Indian boy four years old. 
The dislocation was upon the dorsum ilii, and it was reduced promptly, under 
ether. 4 Dr. Mason, of Leonardsville, N. Y., has reduced a dorsal dislocation in 
a girl of the same age. 5 There are reported a forward dislocation in a boy aged 
five years and a dislocation into the ischiatic notch in a girl of the same age. 
Dr. A. B. Cook, of Louisville, Ky., has reduced a dorsal dislocation in a boy six 
years old. 6 Loewell 7 reduced, in a child four years old, an iliac dislocation 
without difficulty, which had existed twenty-six days. Laurence 8 reduced a 
dislocation in the foramen ovale easily, which was six weeks old, without an 
anaesthetic. 

Dr. J. C. Warren, of Boston, met with an incomplete dislocation toward the 
foramen thyroideum in a child six years old, which, having been displaced eight 
or ten weeks, he was unable to reduce. 9 Sir Astley Cooper mentions a case in 
a girl seven years old. 10 I have myself met with two dislocations upon the dor- 
sum ilii, which occurred at ten years, and one into the foramen thyroideum. 11 
Norris reports a case at eleven years, 12 and Gibson at twelve. 13 

On the other hand, Dr. P. J. Kline, of Portsmouth, Ohio, has reported to me 
a case of dislocation of the femur in a woman aged seventy-three, and which 
thirteen years later he found unreduced ; and Gauthier has seen a dislocation 
of the hip in a woman eighty-six years of age. 1 * The large majority, however, 
occur between the fifteenth and forty-fifth years of life. From an analysis of 
eighty-four cases I have obtained the following results : 

Under 15 years ....... 15 cases. 

15 to 30 " . 32 " 

30 to 45 " 29 " 

45 to 60 " 7 " 

66 to 85 " . 1 ease. r 

Dislocations of the hip are much more frequent in men than in 
women, owing, probably, to the greater exposure of the former to the 
accidents from which these dislocations usually result, and possibly, also, 
in some measure, to certain peculiarities in the form and structure of the 
neck of the femur in the male. 

Of one hundred and fifteen cases collected by me, one hundred and four were 
in males and eleven in females. Dr. J. K. Rodgers, of New York, stated. at a 
meeting of the Kappa Lambda Society that he had seen and reduced four dislo- 
cations of the femur upon the dorsum ilii in females, and that a fifth case had 
recently come to his knowledge in the New York City Hospital. 15 

i New York Journ. Med., Sept. 1848, p. 281. 

2 Ibid., March, 1852, p. 259. 

3 Amer. Journ. Med. Sci., Oct. 1879. 
* Hosp. Gaz., Nov. 15, 1879. 

5 Mason, Med. Gaz., April 21, 1883. 

6 Richmond and Louisville Med. Journ., May, 1878. 
T Loewell, Eec. Mem. de Med. Mil. Janv. Fev. 1876. 

8 Laurence, Centralblatt fur Chir., 1878, No. 11, p. 183. 

9 Boston Med. and Surg. Journ., vol. xxiv. p. 220. 
n A. Cooper, on Disloc., Amer. ed., p. 83, Case 27. 

11 Buffalo Med. Journ., vol. viii. p. 6. Trans. New York State Med. Soc, 1855. My 
Report on Disloc. 

» Amer. Journ. Med. Sci., Feb. 1839, p. 296. 

13 Gibson's Surg., vol. i. p 389. 

14 Gauthier, Malgaigne, op. cit., p. 805. 

15 J. K. Rodgers, New York Journ. Med., July, 1839, vol. i„ first ser., p. 220. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 681 

Gibson mentions an example of dislocation of both thighs at the same moment, 1 
and Schinzinger has reported a case of double dislocation in which the right 
femur was found in the ischiatic notch and the left above the pubes. 2 

Sigonowitz, Andreini, Crawford, Bigelow, Steiner, and Pollard have each 
reported examples of double dislocations of the hip. 3 

§ 1. Dislocations Upward and Backward on the Dorsum Ilii. 

Syn. — "Upward on the dorsum ilii ;" Sir A. Cooper, Miller, Pirrie. " Upward and out- 
ward;" Boyer, Dupuytren. " Upward and backward upon the back of the hip-bone;" 
Chelius. " Iliac;" Gerdy, Vidal (de Cassis), Malgaigne. 

Causes. — Generally they are occasioned by some violence which forces 
the thigh into a state of extreme adduction, or of adduction united with 
rotation inward ; and especially when at the same moment the head of 
the femur is driven upward and backward. Thus, a dislocation upon 
the dorsum may result from a fall from a height, when the force of the 
concussion is received upon the outside of the knee, the thigh being 
thus converted into a lever of the first kind, whose long arm is outside 
of the margin of the acetabulum ; or the dislocation may be occasioned 
by a fall "upon the foot or knee while the limb is adducted, by which the 
head of the femur will be at the same moment driven upward and out- 
ward from the socket. The accident is equally liable to result from the 
fall of a heavy weight, such as a mass of earth, upon the back of the 
pelvis when the body is much bent forward. 

The following case presents an extraordinary example of this form of disloca- 
tion produced by a force acting upon the thigh as a lever of the first kind: B., 
of Rochester, N. Y., set. 10, fell from the top of a high bank, a distance of about 
one hundred feet. Before he reached the bottom of the precipice, he struck 
upon an oblique plane of ice, from which he slid gradually down upon the sur- 
face of the river, which was then completely frozen over. He did not lose his 
consciousness in the descent, nor after his arrest upon the river, but began im- 
mediately to call for assistance. He remembers very well that when he struck 
the glacier, the concussion was recived upon the right side of the right knee, and 
a mark of contusion at this point confirmed his statement. Dr. Ellwood, of 
Rochester, assisted by myself, reduced the dislocation within one hour after its 
occurrence. We employed pulleys, but the reduction was accomplished easily 
in about two minutes, and without the application of much force ; the bone 
resuming its place with an audible snap. His recovery was rapid and complete.* 

Pathological Anatomy. — The capsule is lacerated more or less exten- 
sively, but especially in its posterior half; the round ligament is rup- 
tured ; some of the small external rotator muscles are generally stretched 
or torn completely asunder, the gluteeus maximus, medius, and minimus 
are pushed upward and folded upon each other, the head of the femur 
resting upon or within the fibres of the deep muscles ; the triceps adductor 
is put upon the stretch. Surgeons have not been agreed as to the cause 
of the great difficulty which has sometimes been experienced in the 
reduction of this and of all other forms of coxo-femoral dislocations. 

1 Gibson's Surg., vol. i. p. 385, sixth ed. 

- The International Surgical Eecord, vol. i. No. 2; from "Wiener med. Presse, 1880, No. 
3: Centralb. f. Chir., 1880, No. 11. 

3 Poinsot. op. oit., p. 1007. 

4 Trans. New York State Med. Soc, 1855, p. 76. My report on Dislocations. 



682 



DISLOCATIONS OF THE THIGH. 



While some have ascribed it alone to the resistance of the muscles, others 
have with equal confidence ascribed the opposition to an entanglement 
of the head and neck of the bone in the rent capsule, or to the resistance 
offered by certain untorn ligaments ; and still others believe that the 
impediment ought to be looked for sometimes in the muscles and some- 
times in the untorn portion of the capsule. 



Fig. 433. 



Sir Astley Cooper thought that the capsular ligament was generally too much 
torn to offer any impediment to reduction, and he refers to some dissections in 
confirmation of this opinion. Nathan Smith affirmed that the chief obstacle to 
reduction by extension was to be found in the resistance offered by the glutei 
muscles, which, although at first relaxed, would soon become tense under the 
stimulus of the extension, and which, in order that the bone might resume its 
position, must actually be stretched considerably beyond their normal length. 1 
W. W. Reid declares that the sole resistance is at first in the abductors and 
rotators, but that finally the psoas magnus, iliacus internus, and triceps adductor 
become tense when the pulleys are employed. 2 Chassaignac recognizes no other 
impediment to reduction than the contractions of the muscles. 3 Parmentier, 
in a dissection, found the head imprisoned between the pyramidalis and ob- 
turator internus ; while Servier 5 found the head 
and neck strangled between the pyramidalis 
and the glutseus medius. 

Dr. Fenner, of New Orleans, gives the par- 
ticulars of a dissection of the hip of a man 
admitted into the Charity Hospital, who died 
from injuries received by the bursting of a 
steamboat boiler. His condition being con- 
sidered hopeless, no attempt was made to 
reduce the dislocation. The limb was shortened 
one inch and a half, and the toes turned in- 
ward. Extensive ecchymosis existed. On 
raising the glutaeus maximus and medius, the 
naked head of the femur was found lying on 
the dorsum illi with the ligamentum teres 
hanging to it, but partially torn off. Portions 
of the obturator externus pyriformis, and 
gemelli, were ruptured and lacerated. The 
capsule was torn through one-half of its ex- 
tent. Dr. Fenner now proceeded to cut away 
the muscles, and when all the external muscles 
about the joint had been removed the thigh 
could not be brought down; the iliacus in- 
ternus and psoas magnus were then severed, 
which permitted it to descend a little, but the 
head could not be replaced ; the triceps adduc- 
tor was then divided without effect. The ilio- 
femoral ligament was found tensely stretched. 
All the muscles between the pelvis and the 
thigh were then severed, and still it was impossible to reduce the dislocation; 
the head of the femur could not be forced back through the rent in the capsule 
from which it had escaped ; and it was not until the opening was enlarged from 
one-half to three-quarters of an inch, that the reduction was accomplished. 

Dr. Fenner infers that the capsule possesses sufficient elasticity to allow the 
small head of the femur to pass out through a lacerated opening, which might 




Dislocation upon the dorsum illi. 



1 Surgical Memoirs by N". R. Smith, 1831. 

» Buffalo Med. Journ., 1851. Trans. N. Y. State Med. Soc, 185 2. 

a London Med. Times and Gazette, Dec. 1865, p. 661. 

4 Parmentier, Bull. Soc. Anat., Paris, 1850, p. 177. 

5 Servier, Bull. Soc. Chir. Paris, 1863, p. 485. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 683 

at once contract, so as to offer considerable resistance to its return, and that 
occasionally this is the true explanation of the difficulty in reduction. 1 

Prof. Gunn, of Chicago, says : " In dislocations of the hip and shoulder, the 
untorn portion of the capsular ligament, by binding down the head of the dis- 
located bone, prevents its ready return over the edge of the cavity to its place 
in the socket ; but its return can be easily effected by putting the limb in such 
a position as will effectually approximate the two points of attachment of that 
portion of the ligament which remains untorn." 2 

Dr. Moore, of Kochester, who has often repeated the same experiments upon 
the cadaver, declares, also, that in attempting to reduce the femur by extension 



Fig. 434. 



Fig. 4.35. 




I I \ 



Ilio-femoral ligament. (Bigelow.) Dislocation upon the dorsum illi. (Bigelow.) 

alone he has constantly observed that the untorn portion of the capsule offered 
the main resistance, and that reduction could not be accomplished until this 
was more completely broken up. 3 

Busch, of Bonn, has arrived at similar conclusions ; 4 as also Professors Roser, 
Weber, and Gelle. 

Professor Von Pitha declares that upon a knowledge of the ilio-femoral liga- 
ment is based the correct understanding of the various forms of hip-joint dislo- 
cations. 5 



1 New York Journ. Med., Sept. 1848, p. 268, from New Orleans Med. and Surg. Journ., 
July, 1 848. 

2 Gunn, Paper read before the Detroit Medical Society by Moses Gunn, M.D., A.M., 
LL.D., Professor of Surgery, Rush Med. College, Peninsular Journal, Sept. 1853. 

3 New York Journ. Med., Jan. 1855. 

4 Year-Book of Med. and Surg, for 1864. Sydenham Soc. Publications; from Archives 
of Clinical Surgery, vol. iv. part i. Berlin, 1863. (Poinsot.) 

5 Von Pitha's and Billroth's Surgery, vol. iv., 1865. (Poinsot.) 



684 



DISLOCATION OF THE THIGH. 



A very elaborate exposition of the relations of the ilio-femoral ligament to 
these accidents has been furnished by Dr. Henry J. Bigelow, the Professor of 
Surgery in Harvard University. The following is a brief summary of his opin- 
ions. The ilio-femoral ligament, called by Dr. Bigelow the Y-ligament (Bertin's 
ligament), the internal obturator muscle, and that portion of the capsule of the 
joint which is immediately subjacent, are alone required to explain, and are 
chiefly responsible for, the phenomena of the four regular dislocations. The 
regular dislocations are those in which complete disruption of the ilio-femoral 
ligament has not taken place. The irregular dislocations are those in which the 
ilio-femoral ligament has suffered complete disruption. In reducing either of 
the regular dislocations the limb must be flexed, in order to relax the ilio- 
femoral ligament ; but if other portions of the capsule are not sufficiently torn 
to admit the return of the head within its socket, it must be torn by circumduc- 
tion of the limb. After flexion, and perhaps circumduction, the reduction may 
be completed by rotation, or by extension of the thigh at right angles with the 
anterior surface of the body. The dorsal dislocation owes its inversion to the 
external fasciculus of the ilio-femoral ligament. In the ischiatic dislocation, 
" dorsal below the tondon '' (Bigelow), the head is arrested, in extension, by the 
tendon of the obturator and the subjacent capsule. The flexion and eversion 
of the limb in the thyroid dislodation are due to the ilio-femoral ligament. In 
the pubic dislocation the ascent of the limb is finally arrested by the ilio-femoral 
ligament. 

Fig. 436. Fig. 437. 





Anterior view, showing tense condition 
of anterior and inferior portion of cap- 
sule, and the loose state of the ilio-femoral 
portion in the dorsal dislocation. (Gunn.) 



Posterior view of same specimen, show- 
ing the tense state of the anterior and 
inferior untorn portion of capsular liga- 
ment. (Gunn.) 



Prof. Gunn, who is not fully in accord with Dr. Bigelow's conclusions, says: 
"This portion of the capsule, the Y ligament, is, manifestly, much the strongest, 
and is probably rarely torn asunder in any of the four classical dislocations, 
except the thyroid, in which it is, probably always, completely ruptured, as I 
shall have occasion to demonstrate in the course of the present paper. Its entire 
want of influence in the dorsal variety of dislocation I shall also be able to 
show by exhibition of a dissection of the parts I desire to direct 



UPWARD AND BACKWARD ON THE DORSUM ILII 



685 



attention to another structure which plays an assisting role in holding the head 
of the femur down outside the ridge of the acetabulum in the dorsal disloca- 
tion. If, in an intact state of the muscles and the external portion of the fascia 
lata, the capsular and round ligaments be completely divided, and the head of 
the femur be dislocated upon the dorsum of the ilium, it will be found that the 
characteristic deformity of direction in the limb will be w T anting, i. e., the limb 
will be parallel with its fellow, on a line with the trunk lacking the inversion 
and adduction, but will be shortened the usual extent. If now the limb be 
placed in the position characteristic of dorsal dislocation in the living subject, 
and the reduction be attempted by the old method of extension and counter- 
extension, it will be found that the head is still held down firmly in its hooked 
position outside of the ridge of the acetabulum. It is thus held by the fascia 
lata, which in this position of the limb describes the outermost curve, and conse- 
quently is put upon the stretch and holds the whole trochanteric end of the 
bone pressed firmly inward. 

" These figures," continues Prof. Gunn, " as is the case in all my illustrations, 
are made from a dissection of the parts, which dissection I also herewith exhibit. 
It is seen that the anterior and inferior portion of the ligamentous capsule is 
untorn, tense, and holds the dislocated 



head firmly hooked outside the dorsal 
portion of the rim of the acetabulum, 
while that portion of the capsule be- 
tween the' anterior inferior spinous pro- 
cess of the ilium and the anterior inter- 
trochanteric line of the femur, which is 
reinforced and strengthened by the ilio- 
femoral fibres, is quite loose, owing to 
the approximation of these two points, 
in the shortened, adducted, and intern- 
ally rotated state of the limb which 
characterizes this form of dislocation. 
Thus, this ilio-femoral portion of the 
capsule, in the dorsal dislocation, is en- 
tirely without influence, either in deter- 
mining the deformity or in opposing our 
efforts at reduction. It is entirely to 
the anterior and inferior portion of the 
capsule that these influences are due." 

Symptoms. — The average shorten- 
ing is about one inch or one inch 
and a half, it does occasionally reach 
three inches. The thigh is rotated 
inward, adducted, and slightly flexed 
upon the pelvis. The great toe of 
the dislocated limb, when the patient 
stands erect (and in this position the 
examination ought, if possible, to be 
made), rests upon the instep of the 
foot of the sound limb, and the 
knee touches the opposite thigh near 
the upper margin of the patella. It 
must not be supposed, however, that 
the position of the limb is in all cases 
precisely such as I have described. 
Indeed, the degree of rotation, ad- 



Fio. 438 




Dislocation upon the dorsum ilii. 



duction, flexion, etc., will vary according as the head of the femur is 
more or less displaced, the capsule, including the ligaments, more or less 



686 DISLOCATIONS OF THE THIGH. 

torn ; or as it may be torn in its upper or lower margins, as the muscles 
may be actually rent asunder or only put upon the stretch, and perhaps 
also according to the amount of injury and consequent relaxation which 
they may have sustained from the shock. The thigh can be easily flexed ; 
adduction is more difficult, and abduction is almost impossible, except to 
a very limited extent ; the body of the patient is a little bent forward, 
the roundness of the hip is lost in consequence of the relaxation of the 
glutei muscles ; the trochanter major is depressed, and approaches the 
anterior superior spinous process of the ilium ; and if the patient is not 
fat, and swelling has not already taken place, the head of the femur may 
be felt in its new position rotating under the hand when the limb is 
turned inward or outward, but especially may it be felt when, by flexing 
or extending the limb, the head is made to move downward and upward, 
upon the dorsum ilii. This examination ought to be made, if possible, 
in the erect posture; after which, it will be well to place the patient 
alternately upon his back, upon his sound side, and upon his belly, until 
the diagnosis is rendered complete. 

Sir Astley Cooper affirmed that the limb was sometimes found shortened in 
this dislocation to the extent of three inches. Liston, B. Cooper, Gibson, and 
others, repeat the affirmation. Chelius places the extreme of shortening at two 
and a half inches ; Miller, at two inches ; while Malgaigne declares that he has 
never seen the limb shortened more than half an inch, and that in some cases 
it is not shortened at all, and the very opposite opinions entertained by other 
surgeons he attributes to errors in the measurement. I am certain, however, 
that Malgaigne has fallen into some error. 

The differential diagnosis between dislocation upon the dorsum ilii and 
a fracture of the neck of the femur may be briefly stated as follows. In 
fracture we may expect to find crepitus ; the limb is in most cases mobile ; 
the toes are generally turned out ; the limb is shortened moderately or 
not at all ; the patient is sometimes able to walk for a short distance ; 
fractures of the neck of the femur generally occur in advanced life. In 
dislocation, crepitus is not often present, and only when a fracture co- 
exists ; the limb is immobile, or nearly so ; the toes are turned in ; the 
limb is shortened more ; the patient is unable to bear the weight of his 
body upon his foot for one moment. 

Skey, however, says he has seen a patient with a recent dislocation, who 
walked one-quarter of a mile, to the hospital. I do not think that any other 
similar case is upon record. 

Dislocations of the femur generally occur in middle life. 

Norris, of Philanelphia, mentions an example of hip-disease mistaken for dis- 
location which ought to serve as a warning to prevent similar mistakes. A lad, 
twelve years old was brought to the hospital from a neighboring State, who a 
short time previous had been suddenly attacked with lameness in his right limb, 
and which, by his friends, was attributed to some injury received in play. Two 
physicians, who had been called to see the boy, pronounced him to be laboring 
under dislocation of the hip, and had made two strong efforts with the pulleys 
to reduce it : but after causing great suffering, they gave up all hopes of ever 
replacing the bone, and sent him to Philadelphia. The symptoms were plainly 
those of hip-joint disease in its early stage. The attitude was that assumed by 
those laboring under this affection ; the leg seemed lengthened, but a careful 



UPWARD AND BACKWARD ON THE DORSUM ILTI 



687 



Adult middle life. 

Either sex (men more frequently). 

Severe force. 

Inversion of toes (usually). 

shortening in both. 

If you restore to position displacement does 

not recur. 
No crepitus. 

Preternatural immobility. 
Great prominence of great trochanter.] 

in a child, or in a person under ten 
ial pains to ascertain that it is not a 



measurement showed that it was of the same length with the other; the buttock 
was flattened, and the motions of the joint were tolerably free but painful. 1 
Keen, 2 of Philadelphia, gives the hollowing guide to a differential diagnosis . 

Fracture of Neck. Dislocation. 

Old persons, as a rule. 
In women more frequently. 
Slight force. 
Eversion of toes. 
Shortening in both. 

If you restore to position displacement re- 
curs. 
Usually crepitus. 
Preternatural mobility. 
Slight prominence of great trochanter. 

If the supposed dislocation occurs 
years of age, we ought to take espec 
separation of the epiphysis. 

Examples have occasionally been reported of "everted dorsal dislocations,' 5 
in which most of the usual signs of a dorsal dislocation are present, except that 
the limb is everted, and sometimes slightly ab- 
ducted. Bigelow attributes this condition to a Fig. 439. 
rupture of the outer fibres of the ilio-femoral 
ligament, and he affirms that under these cir- 
cumstances the limb may be found inverted, but 
it is also easily everted ; the foot may be slightly 
everted, it may lie flat upon the bed, or it may 
even point backward. The treatment of the 
everted dorsal dislocation consists in reducing it 
first to an ordinary dislocation by flexion and 
rotation inward, aided by adduction, if necessary. 

Prognosis. — In the large majority of cases 
the patients recover speedily, and in course 
of a few weeks, or months at most, the limb 
seems to be as sound and as useful as before. 



Boyer says the limb remains always weaker th^n 
the other, the round ligament never uniting com- 
pletely; and that inflammation of the cartilages 
and synovial glands may ensue, ending in caries 
of the joint. Such results have, indeed, been oc- 
casionally met with, nor are examples wanting in 
which more rapid inflammation, resulting in the 
formation of acute abscesses, has followed, but 
these are only rare accidents. 

In one case reported from my clinic at Bellevue, 
the patient, aged 33, after I had reduced a recent 
dorsal dislocation by manipulation, walked on the 
fourth day ; and on the seventh day he ascended 
five flights of stairs to the amphitheatre, walking 
without any halt. He declared, also, that he felt 
no soreness or lameness about the hip. 3 




Everted dorsal dislocation. 
(Bigelow.) 



Examples of non-reduction, however, from an error of diagnosis, or, 
what is more pertinent to our present purpose, from a failure to accomplish 
the reduction where the attempt has been made, are numerous. 

1 Norris, Amer. Journ. Med. Sci., vol. xxv. p. 280. College and Clinical Record. 

3 Reduction of a Dorsal Dislocation of the Femur. The Med. Record, Dec. 3, 1876, p. 780. 



688 DISLOCATIONS OF THE THIGH. 

J. M., a German, set, 19, related as follows : " When ten years old, I fell from 
a tree, a height of six feet, and dislocated my left hip. I was then living twelve 
miles from Heidelberg, and I was immediately taken there, but I did not see 
Mr. Chelius until the next morning. He took me to the University, and, before 
the medical class, attempted to reduce it, but he could not. During several 
weeks following, he tried six times, using pulleys, etc., but he could never suc- 
ceed." On examination, I found the limb shortened two inches, the head of the 
femur lying upon the dorsum ilii ; the knee was turned in, but the toes were 
inclined a little outward. He was able to walk rapidly, of course with a mani- 
fest halt, yet without pain or discomfort. > 

Treatment. — Regarding dislocations of the femur upon the dorsum ilii 
as the type of all the coxo-femoral dislocations, the remarks under this 
section may be considered applicable, with only certain qualifications, to 
all the others. The various methods of reduction which have been em- 
ployed by surgeons may be arranged under two principal heads, namely, 
manipulation and extension. It is not possible, however, to classify 
rigidly the different procedures, so as to bring them under these two 
simple divisions, without some violence ; since neither manipulation nor 
extension has usually been employed alone, but almost always some 
degree of extension has been recommended in connection with the manip- 
ulation ; if not in the first instance, at least in the event of the failure 
of manipulation alone ; while, on the other hand, extension is seldom if 
ever practised without manipulation. By these designations respectively, 
it is implied that either manipulation or extension has constituted the 
prevailing feature in the treatment. 

(a) Reduction by manipulation dates from the earliest records of our 
science. Hippocrates says : In some the thigh is reduced with no prepa- 
ration, with slight extension directed by the hands, and with slight move- 
ment ; and in some the reduction is effected by bending the limb at the 
joint and making rotation. 1 

Kichard Wiseman, in 1676, speaks as follow: " If the thigh-bone be luxated 
inward, and the patient young and of a tender constitution, it may be reduced 
by the hand of the chirurgeon, viz., he must lay one hand on the thigh, and the 
other on the patient's leg, and having somewhat extended it toward the sound 
leg, he must suddenly force the kuee up toward the belly, and press back the 
head of the femur into its acetabulum, and it will snap in. For there is no need 
of so great extension in this kind of luxation ; for the most considerable muscles 
being upon the stretch, the bowing of the kaee as aforesaid reduceth it ; yet in 
rough bodies it may require stronger extension." 2 

Eichard Boulton repeated, in 1713, almost the same instructions, affirming 
that this plan was applicable especially to dislocations inward, in the case of 
"young and tender children." 3 

In 1842, Daniel Turner declared that he had reduced three dislocations of the 
hip, one of which was a backward dislocation, by a method combining extension 
with manipulation, but alone " by the strength of the arm or without any other 
instrument." Extension and counter*-extension being made by assistants, and 
" as soon as the surgeon perceives the bone moving out," says Turner, " let him 
take his opportunity, giving orders to the extenders below suddenly to lift up 
the patient's thigh toward his belly, pressing with his hands either to the right 
or left, as the situation of the same requires, and therewith force back its head 

1 Works of Hippocrates, Syd. ed., vol. ii. p. 643. 

2 Eight Chirurgical Treatises. By Richard Wiseman, Serjeant-Chirurgeon to King Charles 
II. London, 1676. Book vii. chap. viii. 

3 A System of Rational and Practical Surgery. By Richard Boulton. London, 1713, p. 
346. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 689 

toward the acetabulum, whereunto it will, flipping over the tip of the cartilage, 
snap sometimes with a loud noise." x 

Thomas Anderson, surgeon, of Leith, in Scotland, was called, in Sept. 1772, 
to see a man who had dislocated his left femur into the foramen thyroideum. 
When he arrived four other surgeons were present, and prepared to use the 
pulleys, which they did in his presence several times, but to no purpose. After 
examining the limb carefully, "I was convinced," says Mr. Anderson, "that 
attempting the reduction in the common method, with the thigh extended, was 
improper, as the muscles were all put on the stretch, the action of which is, 
perhaps, sufficient to overbalance any extension we can apply. But by bringing 
the thigh to near a right angle with the truuk, by which the muscles would be 
greatly relaxed, I imagined that the reduction might more readily take place, 
and with much less extension. When I made this examination, he was lying 
on a table on his back. I raised the thigh to about a right angle with the trunk, 
and, with my right hand at the ham, laid hold of the thigh, and made what 
extension I could. From this trial I found I could dislodge the head of the 
bone. At the same time that I did this, with my left hand at the head and 
inside of the thigh, I pressed it toward the acetabulum, while my right gave the 
femur a little circular turn, so as to bring the rotula inward to its natural situa- 
tion ; and on the second attempt it went in with a snap observable to the gentle- 
men standing around, but more so to the poor man, who instantly cried out he 
was well and free from pain. His knees could then be brought together ; the 
legs were of the same length, and the foot in its natural situation. The knees 
were kept together for some time, with a roller, to confine the motion of the thigh ; 
and in three weeks he was at his work, without the least stiffness in the joint." 
Subsequently Mr. Anderson reduced, by a similar method, a dislocation upon 
the dorsum ilii in a child eight years old, and which had been out nineteen days. 2 

Says Pouteau, in a memoir on dislocations of the thigh upward and outward : 
" We observe, then, first, that the thigh ought to be flexed to a right angle with 
the body during the extension and counter-extension; second, that we ought to 
rotate the thigh from within outward, when the extension appears to be suffi- 
cient; third, that this position puts into relaxation, as much as possible, the 
triceps and gluteal muscles, which oppose the chief resistance to the extension, 
thus saving the patient from excessive pain ; fourth, that the flexion of the thigh 
places the head of the bone in the best position for a return to the cotyloid 
cavity during extension ; fifth, that feeble extension suffices for reduction, 
because all the muscles of the thigh are relaxed." ,H 

On the 7th of January, 1811, Dr. Philip Syng Physick, of Philadelphia, 
reduced an outward dislocation of the hip, after extension had failed, by flexing 
the thigh to a right angle with the body, and then giving to the limb an "out- 
ward circular sweep." 4 

So early as 1815, and perhaps much earlier, Nathan Smith, Professor of Sur- 
gery in the New Haven Medical College, taught that the only correct mode of 
reducing a dislocation upon the ilium was to flex the leg upon the thigh, the 
thigh upon the pelvis, and then to carry the limb diagonally to the opposite 
side, whence it was to be brought outward and downward. 5 Dr. Nathan R. 
Smith gave a more full account of his father's method, illustrating his views of 
the pathology of these dislocations, and the mechanism of their reduction, by 
several drawings. "The patient, being prepared for the operation by whatever 
means may be deemed necessary, may be placed in an attitude convenient for 
the operation, with the body securely fixed, by placing him in the horizontal 
posture, on a narrow table covered with blankets, and on the sound side. To 
the table his body should be firmly fixed, and this can be conveniently done by 
folding a sheet several times, lengthways — then applying the middle of the 
broad band thus made to the inner and upper part of the sound thigh — carrying 
its extremities under the table, crossing them beneath it, and then carrying 

1 The Art of Surgery. By Daniel Turner. London, 1742, vol. ii. p. 339. 

2 Anderson, Medical Commentaries, Edinburgh, 1776, vol. ii. pp. 261-4. 

3 Vidal ( de Cassis) ; from (Euvres posthumes de Pouteau, Paris, 1783. 

4 Physick. Dorsey's Surg., 1813, vol. i. p. 242. Mem. of Nathan Smith, 1831, p. 172. 
Phelps's paper in Trans. New York State Med. Soc, 1856, p. 169. 

5 Trans. N. H. State Med. Soc, 1854, p. 55. 

44 



690 



DISLOCATIONS OF THE THIGH 



them obliquely up and crossing them firmly over the trunk, above the injured 
hip. The ends may then be secured beneath the table. To support the trunk 
more firmly, a pillow may be placed on each side of it upon the table, and 
be included in the bandage. Should the operator design to employ any degree 
of extension, a counter-extending band may be placed in the perineum, and 
carried up to the extremity of the table, to be fixed to some more firm body, or 
held by the hands of assistants. The operator, now standing on the side to 
which the patient's back presents, grasps the knee of the dislocated member 
with his right hand (if the left femur be dislocated — vice versa, if the right), and 
the ankle with the left. The first effort which he makes is to flex the leg upon 
the thigh, in order to make the leg a lever with which he may operate on the 
thigh-bone. The next movement is a gentle rotation of the thigh outward, by 
inclining the foot toward the ground, and rotating the knee outward. Next the 

Fig. 440. 




Nathan Smith's method of reduction by manipulation. (From Smith's " Memoirs.") 

thigh is to be slightly abducted by pressing the knee directly outward. Lastly, 
the surgeon freely flexes the thigh upon the pelvis by thrusting the knee upward 
toward the lace of the patient, and at the same moment the abduction is to be in- 
creased. Professor N. Smith regarded the free flexion of the thigh upon the 
pelvis as a very important part of the compound movement. He believed that 
it threw the head of the bone downward, behind the acetabulum, where the 
margin of the cup is less prominent, and over which, therefore, the abductor 
muscles would drag it with less difficulty into its place. The operator may 
slightly vary these movements, as he increases them, so as to give some degree 
of rocking motion to the head of the os femoris, which will thereby be disengaged 
with the more facility from its confined situation among the muscles." x 

Dr. Luke Howe, 2 of Boston, who was a pupil of Nathan Smith's, gives the 
following account of the method practised by him successfully, about the year 
1820, and which method, he says, was recommended by his preceptor: "The 

1 Medical and Surgical Memoirs, by Nathan Smith, late Prof, of Surgery, etc., in Yale 
College. Edited by Nathan K. Smith, Professor of Surgery in Univ. of Maryland. Balti- 
more, 1831, pp. 163-183. 

2 Boston Med. and Surg. Journ., May, 1840. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 691 

patient was permitted to lie on his back on the bed where I found him, the knee 
of the luxated limb turned in and over the other. I raised the knee in the 
direction it inclined to take, which was toward the breast of the opposite side, 
till the descent of the head of the bone gave an inclination of the knee outward, 
when I made use of the leg, being at a right angle with the thigh, as a lever to 
rotate the latter and turn the head of it inward. It then readily returned to its 
socket, with an audible snap. During this operation, the two assistants who 
had been placed to make the lateral extension and counter-extension, if ulti- 
mately required, were directed to draw moderately at their towels." 

Kluge, in 1825, combined moderate extension with manipulation, by flexing 
both the leg and thigh, while at the same moment the thigh was abducted and 
the knee rotated inward. 1 Wathman, in 1826, directed that the limb should be 
seized by the knee and ankle and slowly lifted forward until it came to a right 
angle with the long axis of the body ; when, if the outward " self-twisting of the 
thigh" occurs, " which cannot be prevented by fast holding," the movement of the 
head of the bone is declared, and it will only remain for the surgeon to let down 
the thigh gradually upon the bed so that the two limbs will come side by side, and 
the reduction will be accomplished. 2 Rust recommended also, in 1826, a similar 
plan, combining moderate extension by the hands, with flexion and abduction 
of the thigh. 3 Colombot, whose opinions date from 1830, suggested that the 
patient should lay himself forward upon a bed or table, no higher than his hips, 
with the sound leg and foot resting upon the floor, and that then the surgeon 
seizing the foot with one hand, so as as to flex the leg, should, with the other 
hand, exercise a moderate degree of extension, and at the same time move the 
limb to the right or to the left, backward and forward, in order to disengage the 
head of the femur ; and, Anally, that he should communicate to the thigh a 
sudden movement of circular rotation, either from within outward, or from with- 
out inward, as the surgeon may choose. 4 Collin states that, in 1833, he had 
reduced four dislocations of the hip by a method very similar to this recom- 
mended by Colombot 5 

Dr. Ingalls, of Chelsea, Mass., reduced a compound dislocation of the femur, 
in which the head of the bone rested upon the pubes, after an unsuccessful 
attempt had been made to reduce it by extension. "An assistant, taking the 
ankle of the dislocated limb in his right hand, and placing his left in the ham, 
bent the leg at right angles upon the thigh, and the thigh upon the pelvis, then 
lifting with a power little more than sufficient to elevate the whole limb, he 
carried it to its greatest state of abduction, at the same time rotating the femur 
inward, while Dr. Ingalls passed his thumb through the wound, and, pressing 
upon the head of the femur, directed it toward the acetabulum. At this moment 
he directed the limb to be forced toward its fellow, by which the reduction was 
effected with the greatest possible ease and elegance." 6 Similar methods of re- 
duction, with only such slight variations as scarcely deserve a special notice, 
have been suggested and practised from time to time by Palletta, in 1818 ; 7 
Despres, in 1835 ; 8 Vial, in 1841 ; 9 Fischer, Mahr, and Clark, in 1849. 10 

In 1851 Dr. W. W. Reid, of Rochester, N. Y., published an account of the 
method practised by himself successfully in three cases of dislocation upon the 
dorsum ilii, the first of which dated from the year 1844. His method, as applied 
to a dislocation upon the dorsum ilii, consists in " flexing the leg upon the thigh, 
carrying the thigh over the sound one, upward over the pelvis as high as the 
umbilicus, and then abducting 1 and rotating it." 11 Dr. Markoe, of New York, 
adopts the same procedure, except that when the limb has been sufficiently 
flexed and abducted, he directs that the limb shall be gradually brought down, 
and he affirms that it is during this last manoeuvre that he has usually found the 
bone resume its place in the socket. 12 Bigelow, of Boston, declares, as has 
already been stated, that in all the regular dislocations, that is to say, in all those 

1 Chelius's Surg., by South, Amer. ed., vol. ii. p. 241. 2 Ibid., p. 239. 

3 Ibid., p. 241, note by South. 

4 Malgaigne, op. eit., vol. ii. p. 825. 5 Ibid., p. 823. 

6 Ingalls, Bransby Cooper's ed. of Sir Astley's English ed., 1842, and Amer. ed., 1852. 

7 Chelins's Surg. ; note by south. 8 Malgaigne. 9 Ibid. 

10 Dublin Med. Press, Dee. 3, 1851. New York Journ. Med., March, 1852. 

11 Reid, Buffalo Med. Journ., vol. vii. pp. 139-143, Aug. 1851. 

12 Markoe, New York Journ. Med., January, 1855. 



692 DISLOCATIONS OF THE THIGH. 

dislocations in which the ilio-femoral ligament is not torn, the thigh must be 
first flexed, in order to relax this ligament, and then reduction may be effected 
by extension directly forward, the thigh being at a right angle with the body, 
or by rotation. In some cases, where there is probably only a button-hole slit 
in the capsule, free circumduction may be required in order that the capsule 
may be torn more freely. His method of reducing the dislocation upon the 
dorsum ilii, is to flex the thigh upon the abdomen, abduct and then rotate out- 
ward ; or, to flex, then adduct and rotate a little inward, to disengage the head 
of the bone from behind the socket, then abduct and pull directly upward. 
When necessary, circumduction is practised to lacerate the capsule more com- 
pletely. 

Prof. Gunn, of Chicago, says : " For the easy reduction of a dislocated hip or 
shoulder, the limb should be placed in, as nearly as possible, the same position 
as that which most frequently characterizes it at the instant of escape." And 
speaking especially of dislocations of the femur upon the dorsum ilii, he adds : 

Fig. 441. 




Relaxation of the ilio-femoral ligament by flexion. (Bigelow.) 

"If we now flex, adduct, and inwardly rotate to a still greater degree, we shall 
loosen the anterior and inferior tense untorn portion which is holding the head 
hooked outside the acetabular ridge, and then by a moderate amount of force 
we may draw the head into the socket. This is most conveniently accomplished 
by putting the patient on the floor on his back ; an assistant fixes the pelvis ; 
the surgeon grasps the limb, flexes and adducts it till it crosses the limb of the 
opposite side at a point as high as the union of the upper with the lower two- 
thirds of the femur ; now rotating the limb inwardly, he will be able to lift the 
head into place by a moderate effort." 

(b) Reduction by extension dates from a period equally early with 
reduction by manipulation. Hippocrates recommended, when other and 
gentler means had failed, to make extension and counter-extension ; the 
extending bands being made fast above the knee and above the ankle, so 
as to distribute the points of pressure; and the counter-extending bands 
being secured around the chest under the armpits, and also, if thought 
necessary, in the perineum of the sound side. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 



693 



Among the methods recommended and practised by Hippocrates, was sitting 
across the upper round of a ladder with a weight attached to the thigh of the 
dislocated limb ; or suspending the patient from a sort of gallows with the head 
downward, and if the weight of the patient's own body proved insufficient, the 
surgeon might add his also; a method which Hippocrates characterizes as "a 
good, proper, and natural mode of reduction, and one which has something of 
display in it, if any one takes delight in such ostentatious modes of pro- 
cedure.'' l 

With various modifications as to the position of the limb, and as to the 
points upon which the extending and counter-extending forces are to be 
applied, and with differently constructed appliances, surgeons have con- 

• Fig. 442. 




Hippocrates's mode of reducing dislocations of the hip by extension. 

tinued to employ extension down to this day. The great majority have 
regarded flexion of the thigh as essential to success ; some holding the 
limb only slightly flexed, and others insisting that flexion should be in- 
creased to a right angle with the body. 

The French surgeons, including Boyer and Vidal (de Cassis), prefer generally 
to apply the extending bands to the feet, in order that the muscles of the thigh 
may not be stimulated to contraction by the pressure of the bandages. Erichsen, 
and the English surgeons generally, make fast the lacq above the knee. The 
French, and most of the American surgeons, recommend the same; but Gerdy 
seeks to multiply the points of application, and for this purpose secures the ex- 
tending band to the whole length of the leg, and to a small portion of the thigh 
above the knee. 

The counter-extending bands are now almost universally made to operate 
against the perineum of the dislocated limb, but Roux, following the practice 
of Hippocrates, places it in the perineum of the sound limb. Gibson recom- 
mends the same practice. Lizars recommends that sometimes the reduction 
should be attempted by simply placing the heel in the perineum and making the 
extension with the hands, very much as Sir Astley Cooper advises us to proceed 
in dislocations of the humerus. Morgan and Cock, of Guy's Hospital, have re- 
duced six cases of dislocation of the hip-joint by placing the foot between the 
thighs, so that it pressed against the upper part of the dislocated bone, and thrust 
it away from the pelvis ; extension and rotation of the limb being made at the 
same time by assistants. 2 Three of these were examples of dislocation upon the 
dorsum ilii, two upon the pubes, and one into the foramen thyroideum ; and most 
of them had occurred in weak or elderly persons. 



1 Works of Hippocrates, Syd. eel., London, vol. ii. p. 641. 

2 Cock and Morgan, Chelius, op. cit., vol. ii. p. 242, note by South. 



694 



DISLOCATIONS OF THE THIGH. 



Ambrose Pare was among the first to recommend the use of pulleys 
for the reduction of dislocations. Most surgeons since his day have 
employed them for the purpose of making extension more energetic and 
steady, and that it might be longer continued. Sir Astley Cooper's plan 
of procedure is as follows : The patient is to be placed on his back upon 



Fig. 443. 




Keduction of a dislocation on the dorsum ilii, by pulleys. (Sir Astley Cooper's method.) 

a table of convenient height between two staples ; a strong padded 
leathern girth or perineal band, constructed so as to receive the thigh, 
and to press at the same moment against the perineum and the outer 
surface of the pelvis, is then applied and made fast to one of the staples 
situated behind the patient in the direction of the axis of the limb. A 
wetted linen roller is next to be tightly applied just above the knee, and 



Fig. 444. 




|,R[i lllfitl'' WW ' ,| - i " 1 " l|! ' ! Hill |: '- f^fi^ ( M!|W<i ,,,£!! 

Keduction of a dislocation on the dorsum ilii, by the Spanish windlass. (Gilbert.; 

upon this a leathern strap is to be buckled, having two short straps with 
wings at right angles with the circular part ; or, instead of this, a round 
towel made in the knot called the clove-hitch. The knee is to be slightly 
bent, but not quite to a right angle, and brought across the opposite thigh 
a little above the knee. The pulleys being now attached, the extension 
is to be commenced. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 



695 



A very simple and efficient mode of making the extension, if one has 
not the pulleys, is to employ for this purpose a small rope, the ends being 
tied together, and the rope being then doubled upon itself once or twice, 
so as to make four or eight parallel cords. The opposite ends of this 
bundle of ropes being made fast to the limb and the staple, the extension 
is made by thrusting a stick through its centre and twisting it. (Fig. 444.) 

Fig. 445. 




Jarvis's adjuster applied for reduction of a dislocation of the hip. 

I have several times had occasion to resort to this plan ; and indeed it has 
been for some time known and practised among surgeons in this country, 1 having 



Fig. 446. 




Bloxham's "dislocation tourniquet" applied for reduction of a dislocation on the pubes. 



been first, according to Professer Gilbert, introduced by Fahnestock, of Pittsburg, 
Pa. It is usually known as the " Spanish windlass." 

1 Gilbert, of Philadelphia, note to Pirrie's Surg. ; also Amer. Journ. Med. Sci., vol. xxxv., 
April, 1845. 



DISLOCATIONS OF THE THIGH. 

Jarvis's adjuster, to which I have already made allusion when speaking of 
dislocations of the humerus, has been often used with success in dislocations of 
the hip as well as in dislocations of the shoulder. 1 Its power is equal to that of 
the pulleys, while the direction of the force can be varied with much greater 
ease. 

Sedillot, a French surgeon, has suggested that when pulleys are used, we 
should measure the exact power employed in the reduction, by an ingeniously 
contrived apparatus called the dynamometer, 2 and which has been variously 
modified by Charriere, Mathieu, Eobert, and Collin. 3 Such an instrument 
might occasionally be useful in preventing the application of excessive force, 
especially when the patient is under the influence of an anaesthetic. 

Appreciation. — Finally, without attempting to determine the precise 
relative value of these different procedures, all of which claim the testi- 
mony of experience, I am prepared to admit that no one of them is 
without merit, and that each may in certain cases possess advantages 
over the others. Precisely what the cases are to which each individual 
method may be especially applicable it would be impossible to declare 
unless the cases were actually before me; and even then it would prob- 
ably be found difficult often to say which was the best until a fair trial 
of one or more, and a final success, had determined the question. The 
time has not yet arrived in which we may institute a rigid comparison 
between the relative merits of the two leading plans of reduction, manip- 
ulation and extension, for while it is true that reduction by manipulation 
has been practised from the earliest day, it is equally true that extension 
has been generally preferred and practised by surgeons in all ages. 
Indeed, it w T as not until Dr. Reid, of Rochester, again called the atten- 
tion of the profession to this subject, illustrating his view T s by the results 
of several successful experiments and by ingenious arguments, that reduc- 
tion by manipulation could be said to have been fairly introduced as an 
established method of practice. 

The following summary of a paper prepared by myself, w T ith the view 
of determining, if possible, the relative value of the two methods, and 
exhibiting an analysis of sixty-four cases in which manipulation was 
employed, will enable the reader to form some estimate of the difficulty 
in which this subject is involved ; and if it does not actually decide a 
moot point, it will at least demonstrate that the method by manipulation 
is not without its hazards. 4 

"Of forty-one cases in which the fact is stated, twenty-eight were reduced on 
the first attempt, seven on the second, four on the third, and tWo on the seventh. 
In seven examples the head of the femur has been thrown from one position to 
another upou the pelvis, travelling from the dorsum of the ilium to the ischiatic 
notch, and from thence to the foramen ovale ; or directly from the dorsum to 
the foramen, and back again ; or in other directions, according to the character 
of the original dislocation ; in some instances these changes being made as often 
as seven times in succession. In the majority of cases no evil consequences 
seem to have followed upon these changes of position. One of my own cases 

1 Crandall, Boston Med. and Surg. Journ., vol. xxxix. p. 77; Atlee, Trans. Amer. Med. 
Assoc, viii. p. 357, 1850. 

2 Amer. Journ. Med. Sci., vol. xv. p. 530. 

3 Poinsot, op. cit, p. 1038. 

* Keduction of Dislocation of the Femur by Manipulation. By the Author. Buffalo 
Medical Journal, Nov. 1857 ,• Feb., March, June', 1859. With tables constructed by my very 
intelligent pupil, Lucien Damainville. 



UPWARD AND BACKWARD ON THE DORSUM ILII. 697 

will especially serve to show with what impunity sometimes these changes may 
be made. 

" J. C, set. 28, was admitted to the Buffalo Hospital of the Sisters of Charity 
with a dislocation of the left femur upon the dorsum ilii, which had occurred 
six days before. No attempt had been made to reduce the dislocation. Five 
times in succession manipulation made by myself failed, leaving the head of the 
bone each time upon the dorsum ilii ; the sixth attempt, made with the addition 
of moderate extension by the hands, threw the head into the foramen thy- 
roideum. By reversing the movements, it was easily replaced upon the dorsum 
ilii. The seventh trial was made in the same manner, except that when I sup- 
posed the head of the bone to be opposite the lower margin of the socket I did 
not permit the limb to turn either outward or inward, but while lifting at the 
knee with my hands, with sufficient power to raise his hips from the table, I 
brought the limb down gradually to a line parallel with the opposite, and thus 
finally the reduction was accomplished. No pain or inflammation followed, 
and. in two weeks he left the hospital ; but whether he was able to walk or not 
at that time, I am unable to say." 1 

The following cases have come to my knowledge : Dr. James R. Wood 
attempted, at the Bellevue Hospital, the reduction of a dislocation of the femur 
upon the dorsum ilii, of five months' standing, in a man 60 years of age. The 
patient was under the influence of ether. Manipulation alone was employed. 
Probably half -an hour had been consumed in the various efforts, when at a 
moment when the thigh was being forcibly abducted, the neck was broken within 
the capsule, and very close to the head. I was able to feel the head of the bone 
distinctly, after the fracture, and to move it freely separated from the neck. Dr. 
David Prince, of Illinois, who was present at the time, informed me that he had 
himself fractured the neck of the femur in attempting the reduction of an ancient 
dislocation of the hip by manipulation. 

In Markoe's paper, 2 several papers similar to my own are reported, in which 
the results have been equally fortunate ; but the case mentioned as having been 
under the cure of Dr. Post, had a more serious termination. This patient, set. 
21, had a dislocation into the ischiatic notch, and on the same day the reduction 
was attempted by manipulation. On the first trial the head of the bone was 
thrown into the foramen ovale; and, after having been moved backward and 
forward between these two points several times, it was finally carried directly 
from the foramen ovale into the socket by manual extension applied in the ordi- 
nary way, but without pulleys. "In this case," says Markoe, "the cure was 
very slow, and he left the hospital with some degree of pain and swelling about 
the joint. I learned that an abscess formed in or about the joint, which was 
opened, and when I saw him, a year after, there was every appearance of seated 
morbus coxarius." In Case 14, of Markoe's paper, the thigh was broken at the 
neck after manipulation had been employed, but while extension was being- 
made by the hands, united with "a lifting outward." Whether the fracture was 
due to the extension, or to the manipulation, seems not to be clearly determined. 
The dislocation had existed seven weeks when this attempt at reduction was 
made. 

Dr. Bigelow has reported a case of dislocation upon the dorsum, of six months' 
standing, in a man 23 years of age, which he attempted to reduce, and caused a 
fracture of the neck of the femur. His account of the manner in which the acci- 
dent occurred is as follows : '' I flexed the limb once slowly upward upon the 
abdomen — a movement which was attended with a continued fine crepitation 
about the hip." Upon examination, the head of the bone was found to be sepa- 
rated from the neck. 

Dr. Dawson has reported a case in which this acccident occurred in his hands. 
Captain Williamson, a gentleman in middle life and fair health, was received at 
Dr. Dawson's clinic with a dislocation into the ischiatic notch of nine weeks' 
standing. He was placed under the influence of ether, and various methods ot 
manipulation employed. At last "more force was used, the thigh was pressed 
forcibly across the abdomen," and this was followed by rapid circumduction. 

1 Buffalo Medical Journal, vol. xiii. p. 682. 

2 New York Journ. of Med., Jan. 1855. 



698 DISLOCATIONS OF THE THIGH. 

At the sixth repetition of this manoeuvre, the neck of the bone suddenly gave 
way. 1 Dr. J. S. Wight, of Brooklyn, broke the femur in an attempt to reduce 
a dislocation of four months' standing. The patient was 53 years old, and the 
head of the femur was thought to be in the ischiatic notch. Under ether the 
thigh was flexed upon the body, and then adducted with moderate force, when 
it broke with a loud snap just below the trochanter. The fragments subsequently 
united. 2 

I have succeeded in collecting sixty-two cases of attempts at reduction by 
extension ; a great majority of which, we find, were reduced in the first trials ; 
but five cases of recent dislocation were not reduced until after several attempts 
had been made. In five cases the femur was broken. The first occurred in St. 
Thomas's Hospital, London. B. W., set. 40, was admitted with a dislocation 
into the ischiatic notch, of twenty-two weeks' duration. An attempt was made 
to reduce the bone by pulleys, in which the reporter professes to believe they 
were successful, but on the following day it was plainly enough not in place. 
Mr. Travers again resorted to extension, and while extension was kept up and 
the assistants were rotating the limb outward, the neck of the femur gave way. 3 
Malgaigne mentions a case in which, while he was himself directing the operation, 
the thigh was broken through its lower third. He was attempting to reduce the 
bone by extension, but it was not until he gave the signal for rotation outward 
that the bone gave way. 4 Gibson says that Dr. Physick, at the Pennsylvania 
Hospital, while engaged in reducing a dislocated thigh by the pulleys, broke the 
femur in consequence of exerting too much force upon it in a lateral direction 
by an additional pulley; and that a similar accident is supposed to have hap- 
pened to Drs. Harris and Randolph in the same hospital, in the year 1838, while 
using the pulleys upon a boy 12 years of age; for during the extension and 
counter-extension, at the moment of rotating the limb, and of drawing it forci- 
bly outward by a towel, a sudden crack was heard. 5 The fifth case is related by 
Sir Astley Cooper as having occurred at the Brighton Hospital, under the care 
of Mr. Gwynne; the dislocation was upon the dorsum ilii, and was supposed to 
have existed about one month. The neck of the femur was broken in the first 
attempt at reduction, and while the surgeon was making extension, with gentle 
rotation. 6 

Sir Astley says : " There are plenty of cases upon record, of fatal abscesses 
from violent attempts at the reduction of dislocated hips." I presume that this 
remark has reference to attempts at reduction by extension, since, in his day, 
this was almost the only mode in use among surgeons. He adds, moreover, that 
Mr. Skey has mentioned a fatal case of phlebitis following protracted extension 
of the thigh. Malgaigne has collected no less than eight similar examples, with 
several more in which serious consequences and even death followed promptly 
upon violent attempts at reduction by mechanical means. 7 

Marchand 8 has reported three cases of paralysis ensuing upon attempts at 
reduction by extension ; in one of which, however, some doubt remains as to 
whether it was due to the extension. 

The head of the bone has been repeatedly thrown from the dorsum ilii into 
the ischiatic notch ; and B. Cooper mentions a case in which the bone was 
carried from the foramen ovale into the ischiatic notch, from which latter posi- 
tion it could not afterward be changed. 9 

As to the relative, chances of failure by the two methods, the testi- 
mony of the recorded cases is equally unsatisfactory. Of the failures 
by extension, the experience of almost every surgeon, the journals, and 
the treatises furnish a sufficient number of examples ; while among the 

1 Dawson, The Clinic, Oct. 17, 1874. 2 Wight, Hosp. Gazette, Sept. 13, 1879. 

3 London Med.-Chir. Bev., Nov. 1828, p. 239. 

4 Malgaigne, op. cit., voi. ii. pp. 146 and 830. 

5 Gibson's Surgery, sixth ed., vol. i. p. 389. 

6 Sir Astley Cooper on Disloc, Amer. ed., p. 88. 

7 Malgaigne, op. cit., vol. ii. p. 164 et seq. 

8 Marchand, These d'agregation, Paris, 1875, p. 76. 

9 Sir Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96. 



UPWARD AND BACKWARD ON" THE DORSUM ILII. 699 

sixty-four cases of attempts at reduction by manipulation collected by 
me, and, excepting the cases in which the bone was broken, only two 
were positive failures. 

It is somewhat remarkable, however, that these two cases occurred in the 
experience of the New York City Hospital ; and that they are taken from a total 
of fifteen, this being the whole number which had been treated by this method 
at the date of these observations, in the New York Hospital. One had existed 
one month, and, after repeated trials by manipulation and frequent changes of 
position, it was finally reduced by pulleys. The other, a dislocation into the 
ischiatic notch, had existed only a few hours. At least seven or eight trials 
were made to accomplish the reduction by manipulation, but without success. 
The first attempt by extension failed also, but in the second attempt the femur 
was kept at a right angle with the body, and the bone was soon brought into its 
socket. 1 We have in these two examples not only a record of failure by manipu- 
lation, but an equal record of success by extension ; while, on the other hand, 
we find, in an analysis of the sixty-four cases, sixteen triumphs of manipulation 
over extension. 

My present convictions upon this subject are that manipulation, owing 
to the greater power which may be brought to bear upon the neck and 
head of the bone through the action of the shaft of the femur as a lever, 
is most liable to throw the head of the bone into new positions, and con- 
sequently most liable to rupture the various soft tissues about the joint ; 
to produce inflammation, suppuration, and caries. For the same reason 
it is most liable, also, to fracture the neck of the femur. It is not cer- 
tain in my mind but that, when the principles which control the reduc- 
tion are more completely understood, these evils may be lessened ; yet I 
can scarcely persuade myself that by any future observations the state of 
the question will ever be greatly changed. I cannot but think, also, 
that some conclusions ought to be drawn from the circumstance that, 
since the time of Hippocrates to the present day, manipulation has been 
occasionally recommended and successful examples reported : the reduc- 
tion being accomplished in most instances by processes identical, or nearly 
so, with those now adopted ; yet generally the writers appear to have 
been ignorant of what had been done before, and, indeed, they have gen- 
erally avowed their belief that the method suggested by themselves was 
altogether new and original. Possibly this slowness to establish, and 
total inability to sustain and perpetuate, a reputation was not the fault 
of the method, and had no relation to its failures. Until within a few 
years the number of surgical books, and especially of medical journals, 
was comparatively very small, so that valuable truths often died with 
their discoverers, or were known and remembered only by a few ; but it 
is possible, also, that it has a deeper significance, and that it implies 
some defect in the procedure, or serious danger, in consequence of which 
it has from time to time lapsed into desuetude and finally into complete 
oblivion. 

Method of Manipulation. — The rules which the author would give 
for the employment of manipulation are very simple. The patient being 
laid on his back upon a mattress, the surgeon, assuming that it is a dis- 
location upon the dorsum ilii, should seize the foot with one hand and 

1 Van Buren, New York Med. Times, Jan. 185fi, p. 126. 



700 



DISLOCATIONS OF THE THIGH. 



the other he should place under the knee ; then, flexing the leg upon 
the thigh, the knee is to be carefully lifted toward the face of the patient 
until it meets with some resistance ; it must then be moved outward and 
slightly rotated in the same direction until resistance is again encoun- 
tered, when it must be gradually brought downward again to the bed. 



Fig. 447. 




The Author's method. First position. 



I do not know that the whole process could be expressed in simpler or 
more intelligent terms than to say, that the limb should follow 
stantly its own inclination. 



con- 



All writers have united in the necessity of flexion ; and, indeed, with very 
few exceptions, the advocates of extension have insisted upon carrying the dis- 
located limb more or less across the sound one ; or of making the extension at 
right angles with the body. They have also been nearly unanimous in their 
statements that the thigh'should then be abducted and finally brought down. 
Nathan Smith has added the injunction to rotate the shaft of the femur outward, 
and to press gently upon the inside of the knee while the thigh is being flexed 
upon the body, so as to compel the head of the bone to hug the outer margin of 
the acetabulum and to prevent its falling into the ischiatic notch; a suggestion 
which has been erroneously interpreted by some writers to mean that he would 
carry up the limb abducted, a thing which is simply imply impossible until the 
reduction is accomplished. In adopting this practice, however, we must not 
forget the danger which we incur, when the limb is completely flexed, and the 
head of the femur is below the edge of the acetabulum, of throwing it over into 
the foramen ovale. Dr. Nathan Smith has also noticed the advantage which 
sometimes may be gained by giving to the limb at this moment a slight rocking 
motion. 



UPWAED AND BACKWARD ON THE DORSUM ILII. 701 

These movements of the limb, with perhaps other slight modifications, 
such as lifting the knee moderately or forcibly when the bone refuses to 
mount over the margin of the acetabulum, pressing with the hand or foot 
upon the pelvic bones, and violent circumduction, are all which have 
been usually practised in successful manipulation. As a general rule, in 
the first trial, the knee must be carried only in those directions which 
offer no resistance, and these will be found almost always to be the same ; 
the knee of the dislocated femur hano-ino; over the sound one will be 
made easily to ascend to about a right angle with the body ; we can then 
carry it outward a short' distance, probably not more than four or five 

Fig. 448. 




Second position. Not often required. Liable to cause secondary dislocation into ischiatic 

notch or foramen ovale. 



degrees ; at this moment, frequently, the thigh will begin to rotate out- 
ward of itself, and with considerable force, or, as Wathman says, " a self- 
twisting of the thigh occurs, which cannot be prevented by fast holding." 
When this action takes place the reduction is immediately accomplished ; 
and it is, in fact, at this moment, before the limb begins to descend, that 
the bone most frequently resumes its socket. If it does not, then as soon 
as the limb begins to fall the reduction occurs, generally with a loud snap. 
It is pretty certain that this manipulation is to fail if the knee has de- 
scended more than a few inches without the reduction having taken 
place ; and it. will be better to repeat the manoeuvre at once, rather than 
to bring the limb completely down. 



702 



DISLOCATIONS OF THE THIGH. 



Generally anaesthetics ought not to be employed, since the operation, 
if successful, is not usually painful, and we need that the patient should 
preserve his consciousness, in order to admonish us when we are using 
improper violence. It is probable, also, that the action of certain mus- 
cles sometimes affords material assistance in the reduction. If, however, 
the patient is very sensitive, or the parts about the joint are very tender, 
or manipulation without anaesthetics has failed, then certainly these 
agents may be properly and advantageously employed. If we propose 
to attempt reduction by extension, it is no longer necessary to resort to 

Fig. 449. 




Third position. 

the lancet, antimony, and the hot bath, as preliminary measures, since 
the muscles can be at once overcome by the much more certain and more 
powerful agents, chloroform, ether, etc. 

Method of Extension. — The method recommended by Sir Astley 
Cooper, and most often practised by surgeons of the present day, is essen- 
tially as follows : The patient is placed upon a bed of suitable height, 
reclining on his back, but partly over upon the sound side. Observing 
now the line of the axis of the dislocated thigh, one strong staple is to be 
secured into the wall upon one side of the room, and another upon the 
opposite side, both of which shall correspond as nearly as possible with 
the line of the shaft of the femur. The staple in front of the body will 
be higher than the bed, and the staple behind will be, in the same pro- 
portion, lower than the bed. The limb being stripped, two pieces of 
strong factory cloth, each about four inches wide and two feet long, should 



UPWARD AND BACKWARD ON THE DORSUM ILII. 703 

be laid parallel with and on each side of the limb ; the centre of each 
strip being about opposite that portion of the thigh which is just above 
the two condyles. Over the centre of these strips, above the condyles 
and patella, a strong roller, three inches wide, and at least three yards 
long, previously wetted in water, is to be turned as tightly as it can be 
drawn until the whole roller is exhausted ; the extremity of the roller 
being made fast with a needle and thread rather than with pins. The 
upper ends of the side strips are then to be brought down, and tied to 
the lower ends, forming thus two lateral loops, upon which one of the 
hooks of the compound pulleys is to be made fast, while the other hook is 
secured to the front staple in the wall. Instead of these rollers we may 
employ, if we choose, a leathern thigh-belt. For the purpose of counter- 
extension a sheet is folded diagonally, and its centre being applied to the 
perineum of the dislocated limb, the ends are tied firmly into the back 
staple. To prevent the body from moving laterally, under the action of 
the pulleys, one assistant should be seated upon the bed, with his back 
against the side and back of the patient, and his right arm thrown over 
the body ; it is well also to station another beside the sound limb, so as 
to retain it also in its place upon the bed. Underneath the upper part 
of the dislocated limb a strong and broad bandage should be placed, of 
sufficient length to tie over the neck of the surgeon when he is standing 
about half-bent over the body of the patient. 

Everything being arranged, and all portions of the apparatus having 
been sufficiently tested to make sure that nothing will give way during 
the operation, the ansesthetic is to be administered, and as the patient 
falls gradually under its influence, the action of the pulleys should com- 
mence, and be slowly but steadily increased ; a third assistant managing 
the rope, so as to leave the surgeon unembarrassed, and able to direct 
his whole attention to the position of the trochanter major and of the 
head of the femur. In order to this, he should place one hand upon each 
of these prominences, and watch carefully their descent. 

The length of time which will be required to bring down the limb must differ 
greatly in different persons, according to the peculiar circumstances of the case, 
and the condition, age, etc., of the patient ; but it must never be forgotten that 
a slow and steady action is much more effective than rapid and irregular trac- 
tions, and it is in this especially, rather than in the relative amount of power, 
that the pulleys possess always so great an advantage over the hands. 

When the surgeon finds that the head of the bone has nearly or quite 
reached the socket, if it does not take its place spontaneously, he may 
place his neck in the noose which passes underneath the thigh, and lift 
upward and outward, in order to raise the trochanter major, and thus 
enable the head to rotate toward the acetabulum. It is in this part of 
the manoeuvre, and especially when at the same moment one of the 
assistants, after bending the leg upon the thigh so as to make of it a 
lever, has rotated the thigh outward, that the fracture of the neck has 
generally taken place; and we cannot be too cautious, therefore, parti- 
cularly in old persons, not to bear very strongly upon the noose, nor to 
permit the assistant to rotate outward with great force. If the bone 
does not enter the socket, we may increase the flexion, or suddenly 
release the tension, or, in fine, again resort to manipulation alone. When 



704 



DISLOCATIONS OF THE THIGH. 



the reduction is accomplished, the patient should be laid upon his back, 
with the knees resting over a pillow, and tied together lightly with a 
towel or a strip of cotton cloth. In order also the more certainly to pre- 
vent a redislocation, the thigh of the dislocated limb should be gently 
rotated outward, by which the head will be pressed forward against the 
anterior portion of the capsule. 

Such an accident, however, as a recurrence of the dislocation, in the case of 
the femur, is exceedingly rare; and I should have deemed it altogether impos- 
sible, except as the result of considerable violence again applied, had not at 
least two examples been reported to me upon very excellent authority. Mal- 
gaigne says he has himself seen an example of redislocation upon the dorsum 
ilii, occasioned by an untimely movement; 1 and Verneuil has seen, ten days 
after the reduction of a dislocation upon the ischiatic notch, the dislocation 
reproduced by a sudden effort of the patient to sit up; 2 indeed, it is when the 

Fig. 450. 




Tripod for vertical extension. (Bigelow.) 

limb is in a flexed position that the accident seems most likely to occur. In 
these remarks I mean to except those cases in which the upper margin of the 
acetabulum is broken off, and the head of the femur has consequently lost its 
natural support in this direction. The possibility of this accident is also con- 
firmed by the examples of " voluntary " dislocations, which I shall relate in the 
last section of this chapter. 

Bigelow's Method of Lifting. — The method of extension recommended by Dr. 
Bigelow, namely, with the thigh at a right angle with the body, has already been 
referred to ; and there is much reason to believe that, as a rule, it is preferable 
to extension as practised by Sir Astley Cooper. Nearly all surgeons, however, 



Malgaigne, op. cit., torn. ii. p. 830. 



Ibid., p. 840. 



UPWAED AND BACKWARD ON THE DORSUM IL1I. 705 

have recognized the necessity of flexing the thigh in certain cases. Dr. Bige- 
low suggests that where greater force is required than can be obtained by the 
usual methods, a tripod should be employed, as shown in the accompanying 
woodcut. 

[Bigelow 1 expresses himself thus: "If there is any single and best rule for 
reducing a recent dislocation of the hip, it is to get the head of the femur 
directly below the socket by flexing the thigh at about a right angle, and then 
to lift or jerk it forcibly into its place. The rule applies to all dislocations 
except the pubic, and even to that when secondary from below the socket. The 
reduction by the lifting method is usually instantaneous, and flexion is at the 
basis of its success. If after one or two trials it should appear that the hip can- 
not be jerked into place, let the rent in the capsule be enlarged a little by 
moving the flexed thigh, not up and down, but from one side to the other, so as 
to sweep the head of the femur across below the socket. No danger need be 
apprehended from this expedient of circumduction. The added injury is a very 
slight one Such additional laceration may sometimes advantage- 
ously occur without the knowledge of the surgeon during unsuccessful efforts to 
reduce the bone, especially in executing the manoeuvres described in the rule : 
flex, abduct, evert." 

The advantages of this method may be thus stated : Flexion relaxes the ilio- 
femoral ligament, and the relaxation may be further increased by slight adduc- 
tion ; then rotate very slightly inward, that is to say, move the foot away from 
the middle line while the knee is held steady; this disengages the head from 
behind the socket ; slight traction in the line of the femur will then usually 
bring the bone into position ; if more force is required, the surgeon may place 
his foot, covered with a stocking, on the anterior superior spinous process, to 
steady the pelvis while he raises the bent knee. (Fig. 451.) 

Fig. 451. 




Reduction bv lifting;. ' 



Dr. J. E. Kelly 2 fixes the patient in the recumbent position by straps or band- 
ages around the hips and the board on which he lies ; the thigh being bent at 
right angles with the body, the surgeon stands astride the leg facing the patient ; 
stooping and passing his arms under the leg near the knee, the leg is brought 
against his perineum, and he is able to lift to great advantage. (Fig. 452.)] 



London Lancet, June 15, 1878. 



Dublin Journ. Med. Sci. 



45 



706 



DISLOCATIONS OF THE THIGH 



The following case, reported by Dr. Fanning, of Catskill, N. Y., illustrates 
the occasional necessity of resorting to extension, and is of special interest on 
account of the extreme youth of the patient. I have referred to the same case 
once before. A little girl, two and a half years old, was caught under a falling 
door; her parents suspected no injury beyond a severe bruise until ten days 



Fig. 452. 




\ \ \ 

Reduction by lifting. (Kelly.; 



later, when they consulted Dr. Fanning. The left femur was then found to be 
dislocated upon the dorsum ilii. Dr. Fanning attempted first to reduce the dis- 
location by manipulation, but he failed. He then directed the father to make 
extension by the legs, while the mother made counter-extension by seizing the 
child under the arms, and thus he soon succeeded in effecting the reduction. 



§ 2. Dislocations Upward and Backward into the Great Ischiatic Notch. 

Syn. — " Upward and backward into the ischiatic notch ; " Sir A. Cooper. " Upward and 
backward into the great sacro-sciatic notch ; " Lizars. " Backward into the sacro-sciatic 
foramen;" S.Cooper. "Backward into the ischiatic notch;" Liston, B. Cooper, Miller, 
Pirrie, Erichsen, Skey, Gibson. "Downward and outward on the os ischium:" Boyer, 
Dorsey. "Backward and downward into the ischiatic notch;" Chelius, Petit, Duverney. 
"Upon the ischium; " Bertrandi. "Sacro-sciatic;" Grerdy. "Ischiatic:" Malgaigne. 
" Dorsal below the tendon ; " Bigelow. 

Causes. — A fall upon the foot or knee when the limb is very much in 
advance of the body ; or the fall of a heavy weight upon the back and 
pelvis when the thigh is nearly or quite at a right angle with the body. 
Indeed, the causes are very similar to those which produce dislocations 
upon the dorsum ilii, except that it is necessary to suppose the limb in a 
position more nearly at a right angle with the trunk, at the moment at 
which the force is applied. 

Pathological Anatomy. — Mr. Syme dissected the body of a man 
recently dead whose thigh had been dislocated into the ischiatic notch. 
He found the glutaeus maximus nearly torn asunder, the head of the 
femur being embedded in its substance ; the gluteeus minimus, the pyri- 
formis, and the gemellus superior lacerated ; the capsular ligament exten- 
sively torn close to the edge of the acetabulum, and the round ligament 
completely separated from the femur. The head of the femur was lying 
in the great ischiatic notch, upon the gemelli and the sacro-sciatic nerve, 



UPWARD AND BACKWARD INTO ISCHIATIC NOTCH 



707 



behind the acetabulum and a little above it ; being situated between the 
uppermargin of thenotch and the great sacro-sciatic ligaments. 1 (Fig. 453.) 



Fig. 453. 



Fig. 454. 





Dislocation upward and backward into 
the great ischiadic notch. (A. Cooper.) 

Boyer considers this dislocation 
as only secondary upon a disloca- 
tion upon the dorsum ilii; but it 
is very certain that it often occurs 
as a primary accident. Not un- 
frequently, also, what was prima- 
rily a dislocation into the ischiatic 
notch, becomes subsequently a dis- 
location upon the dorsum ilii. 

Dr. Hutchison, of Brooklyn, N. 
Y., has reported an example of 
this dislocation in which, death 
having occurred four days after 
reduction, he was able to ascertain 
the character of the lesions. I 
was present at this autopsy, and 

the lesions were found to be much the same as in the case related by Syme ; but 
the glutseus minimus was not torn, and there was added a laceration of the ob- 
turator externus. Dr. Lente has reported one other dissection made after 
reduction. 2 

Dr. Bigelow speaks of a dorsal (upon the ilium) dislocation as sometimes 
occupying a position as low as the upper portion of the ischiatic notch ; but 
the dislocation now under consideration he describes as that in which the head 
of the femur, having been driven from its socket downward and backward, is 
subsequently, in the attempt to straighten the limb, carried upward behind the 
socket until it is arrested by the strong tendon of the obturator internus, and 



Dislocation upward and backward into the grea 
ischiatic notch. 



1 Amer. Journ. Med. Sci., vol. xxxii. p. 460. 

2 Lente, New York Journ. Med., Jan. 1851. 



i 



708 



DISLOCATIONS OF THE THIGH. 



the subjacent capsule. This is usually denominated "ischiatic;" but as it is 
both behind and below the tendon, Bigelow calls it " dorsal below the tendon." 

Fig. 455. 




Internal obturator in its natural position. (Bigelow.) 

Quain 1 made a careful dissection of a recent ischiatic dislocation, in which no 
ittempt at reduction had been made. The head of the femur rested upon the 

ischiatic spine, and was separated from the 
pelvic bones only by the obturator internus 
and the gemelli. The pyramidalis, situated 
above the head of the femur, was moderately 
stretched. The gemelli and obturator internus 
were greatly stretched ; which last-mentioned 
muscles, with the capsular ligament, alone 
separated the head from the cotyloid cavity, 
and from the surface of the innominatum 
situated behind this cavity. The external 
obturator and the quadratus were torn trans- 
versely. The capsule was detached from the 
cotyloid margin at its inferior and internal 
insertions, while its posterior and external 
portions were intact. The round ligament 
was torn from its insertion into the head of 
the femur. 

In a case reported by Scott, 2 the sciatic 
nerve was compressed between the head and 
the ischium. 



Symptoms. — The position of the limb 
is in some cases nearly the same as in 
certain dislocations upon the dorsum. It 
is shortened usually about half an inch, 
the thigh being flexed upon the body, 
adducted, and rotated inward; but the 




Showing tense condition of ante- 
rior half of capsular ligament in 
"backward" dislocation. (Gunn.) 

1 Quain, Poinsot, op. cit., p. 1054. 



2 Scott, Dublin Hosp. Rep., 1S22, vol. 3, p. 



UPWARD AND BACKWARD INTO ISCHIATIC NOTCH. 709 

flexion is often less than in dislocations upon the dorsum, while, on the 
other hand, it is sometimes much greater. Generally it is such that, 
when the patient is standing, the end of the great toe of the dislocated 
limb touches the ball of the great toe of the sound limb. 

Bigelow observes that the extreme flexion which is sometimes found to* exist 
especially when the patient is in the recumbent position, is generally due to the 
arrest of the head of the femur by the internal obturator and the subjacent un- 
torn capsule. When the patient rises, the weight of the limb may force the 
head up behind the tendon of the obturator ; or if the limb is brought down 

Fig'. 457 





N§ 




- 



w 



Internal obturator in its new position. (Ischiatic) " Dorsal below the tendon." 

(Bigelow.) 

with force, the tendon and capsule may give way and the head may ascend to 
any point upon the outer surface of the ilium, and in this way an ischiatic may 
be converted into an iliac dislocation. 

The head of the femur is sometimes distinctly felt in its new position, 
especially when the limb is moved upward or downward. The trochanter 
major is approximated toward the anterior superior spinous process of 
the ilium. 

Sir Astley Cooper remarks that this dislocation is the most difficult to detect, 
and Mr. Syme mentions a case in which the nature of the accident was over- 
looked by himself, and the thigh was not reduced until the thirteenth day ; l and 
subsequently Mr. Syme has called attention to what he considers as one of the 
most important diagnostic marks — indeed, he says it is never absent, nor is it 
ever met with in any other injury of the hip-joint, " whether dislocation, fracture, 
or bruise ; " this is " an arched form of the lumbar part of the spine, which can- 
not be straightened so long as the thigh is straight, or on a line with the patient's 
trunk. When the limb is raised or bent upward upon the pelvis, the back rests 

1 Amer. Journ. Med. Sci., vol. xviii. p. 242. 



710 



DISLOCATIONS OF THE THIGH. 



Fig. 458. 




K 



ik^ 



Dislocation upward and backward into 
great ischiadic notch. " Below the ten- 
don," when the patient is recumbent. 
(Bigelow.) 



flat upon the bed ; but so soon as the limb is allowed to descend, the back be- 
comes arched as before." * This position, assumed by the back when an attempt is 
made to straighten and depress the limb, is due to the action of the psoas magnus 
and iliacus internus. But this can hardly be regarded as absolutely diagnostic, 

inasmuch as this same phenomenon will 
be observed in a degree, more or less, in a 
dislocation upon the dorsum, and in most 
cases of disease of the hip-joint. The in- 
version of the toes, immobility of the limb, 
and the absence of crepitus, are generally 
sufficient in themselves to distinguish it 
from a fracture of the neck. Dr. Squires, 
of Elmira, N. Y., suggests, also, that in 
ancient cases the projection of the head 
of the femur may be felt by passing the 
finger into the rectum or vagina. With 
my finger in the rectum I determined a 
dislocation into the ischiatic notch which 
had existed six months, in a boy 12 years 
old ; and by exploration per vaginam I 
diagnosticated the same dislocation in a 
woman at Bellevue Hospital, which had 
existed four weeks. 

Dr. Oscar H. Allis, of Philadelphia, has 
added another valuable means of diag- 
nosis, namely, that, although the limb, 
when laid parallel with the other, or as 
nearly so as it is practicable to place it, 
and extended, will be found to be only 
very little shortened, if at all ; yet, when 
the two limbs are brought into a position of flexion, the thighs being at right 
angles with the body, the dislocated limb will appear one or two inches shorter 
than the other — that is, the knee of the dislocated limb will be on a much lower 
level than the other. 2 

Dr. W. Dawson, of Cincinnati, whose observations in relation to this new sign 
extended back as far as 1871, and who had repeated the observation several 
times, published his experience in 1878, without being aware that Dr. Allis had 
already called the attention of the profession to this point. 3 

I have seen two dislocations of this character which were not recognized by 
the surgeons at the time of the receipt of the injury, nor for some weeks after- 
ward. One was a lad 12 years old. The accident had happened eight weeks 
before. His limb was shortened one inch ; it was also forcibly adducted and 
rotated inward. Dr. Colegrove, a very excellent surgeon, had made a thorough 
attempt to reduce the dislocation with pulleys a few days before he was brought 
to me, and I did not deem it advisable to subject him again to the trial. Not- 
withstanding the dislocation, his limb was quite useful. The second was in the 
case of the boy seen by Dr. Sayre and myself, to which I have referred. 

Treatment. — In employing manipulation, we may follow, with only a 
slight modification, the directions already given in dislocations upon the 
dorsum ilii. We find the head of the femur lower ; consequently the ex- 
tent of the circuit to be described in the manoeuvre is diminished, but in 
other respects the processes are identical. We must not forget, however, 
that there is especial danger, while attempting to reduce this dislocation 
by manipulation, that the head of the bone will be thrown across into the 
foramen thyroideum. 

1 Amer. Journ. Med. Sci., Oct. 1843, p. 461, from Lond. and Edinb. Month. Journ., July, 
1843. 

2 Allis, Phila, Med. Times, March 28, 1874. 

3 Dawson, Archives of Clinical Surg., Jan. 1, 1878. Hosp. Gaz., May 16, 1878. 






UPWARD AND BACKWARD INTO ISCHIATIC NOTCH. 711 

I have already mentioned one case occurring under the care of Dr. Post in the 
New York Hospital, in which the head of the femur, originally in the ischiatic 
notch, passed backward and forward between the ischiatic notch and the fora- 
men thyroideum many times, and which, although the reduction was finally 
accomplished, was followed by morbus coxarius. Parker mentions a second 
case in the same paper, 1 in which his first attempt to reduce by manipulation 
carried the head of the bone into the foramen thyroideum; but the second 
attempt was successful. In Dr. Hutchison's case, to which I have already 
referred, the first attempt at reduction was made without an anaesthetic, and by 
manipulation after the method described by Eeid. The first two attempts failed, 
and in the third, the limb being more abducted than before, the head of the 
bone was thrown into the foramen thyroideum. By reversing the movements, 
it was replaced in the ischiatic notch ; and this change of position was made 
seven or eight times. The patient was now etherized, and the bone was lifted 
into its socket in the same manner which I have described in the case of Caswell. 
Malgaigne refers to a patient of Lenoir's, and to another of his own, in which 
the head of the bone was lodged under the margin of the acetabulum during the 
attempts at reduction. 2 

C. McC, set. 21, a laborer, was caught between two cars, with his back resting 
against one car, and his right knee against the other,, the right thigh being 
raised to a right angle with the body. As the cars came together he felt a 
" cracking" at the hip-joint, and found himself immediately unable to walk or 
stand. Two hours after the accident I examined the limb carefully, and made 
arrangements for the reduction with the pulleys, in case the attempt by manipu- 
lation should fail. The patient lying upon his back, 1 seized the right leg and 
thigh with my hands, the leg being moderately flexed upon the thigh, and car- 
ried the knee slowly up toward the belly, until it had approached within twelve 
or fifteen inches, when, noticing a slight resistance to farther progress in this 
direction, I carried the knee across the body outward, until I again encountered 
a slight resistance, and immediately I began to allow the limb to descend. At 
this moment a sudden slip or snap occurred near the joint, and I supposed reduc- 
tion was accomplished ; but on bringing the limb down completely, I found it 
was still in the ischiatic notch. I think the head had slipped off from the lower 
lip of the. acetabulum, after having been gradually lifted upon it. 

Without delay I commenced to repeat the manipulation, and in precisely the 
same manner. Again, at the same point, when the limb was just beginning to 
descend, a much more distinct sensation of slipping was felt, and on dropping 
the limb it was found to be in place and in form, with all its mobility completely 
restored. No anaesthetic was employed, and no person supported the body or 
interfered in any way to assist in the reduction. No outcry was made by the 
patient, yet he informed me that the manipulation hurt him considerably. The 
amount of force employed by myself was just sufficient to lift the limb, and the 
time occupied in the whole procedure was only a few seconds. After the reduc- 
tion he remained upon his back, in bed, eleven days, in pursuance of my in- 
structions. At the end of this time he began to walk about, but was unable to 
resume work until after eight weeks or more. It is probable that he could have 
walked immediately after the reduction, without much if any inconvenience, so 
trivial was the inflammation which resulted from the accident. He never com- 
plained of pain, but only of a slight soreness back of the trochanter major, near 
the head of the bone. This soreness continued several weeks, and was especially 
present when he bent forward. After the lapse of four months, when I last saw 
him, he occasionally felt a pain at this point in*stooping, but the motions of the 
joint were free; he walked rapidly and without halt. 

Perhaps in most cases, and especially when the head of the bone has 
not been carried by consecutive displacement upward until it rests fairly 
upon the lower portion of the dorsum ilii, the most important step in the 
manoeuvre is to lift the bone toward the socket, by placing the arm 

1 Markoe's paper, N. Y. Journ. of Merl., Jan. 1855. 
- Malgaigne. op. cit., torn. ii. p. 839. 



712 



DISLOCATIONS OF THE THIGH. 



under the knee (the patient resting upon his back) and drawing directly 
upward. 

Prof. Gunn, describing his method, says: An assistant fixes the pelvis while 
the surgeon flexes the thigh at a right angle with the trunk, and the leg upon 
the thigh ; he then adducts, rotates inwardly, and draws the limb forward in the 
direction. of extreme adduction, thus lifting the head directly into the socket. 
Essentially Prof. Bigelow adopts the same method. 

If the reduction is attempted by extension, we ought to remember that 
the head of the bone lies more behind than above the socket, and that it 
is not requisite to carry it downward so much as forward ; and especially 
that it must mount over the most elevated margin of the socket, in order 
to resume its position. The extension ought, therefore, to be made at a 
right angle with the body. 

J. H., set. 40, had a dislocation of the head of the femur into the ischiatic 
notch. He entered Bellevue Hospital about twenty hours after the accident. 
In the recumbent posture the limb was pretty strongly adducted and slightly 
rotated inward. It was shortened three-quarters of an inch. In the erect pos- 

Fig. 459. 




Reduction of dislocation upward and backward into the great ischiatic notch, by extension- 
(Sir Astley Cooper's method.) 

ture both adduction and inward rotation were very slight. Having etherized 
him, I made three separate attempts at reduction by manipulation, but failed. 
I then made extension in the following manner: The patient resting upon his 
back, I stood astride his body, and clasping my hands under the knee, I pulled 
directly upward, while an assistant held down the pelvis. I did not feel the 
bone resume its place, nor was I aware that reduction was accomplished, but 



INTO THE FORAMEN THYROIDEUM. 713 

when I let the limb down the bone was found to be in its socket. Two or three 
minutes later, and before the patient had recovered from the effects of the ether, 
I raised the knee, to indicate to some young men, who had just come in, how 
the dislocation had been reduced, when it slipped out again, with a sudden jerk 
and a grating sensation. This sensation I had felt once or twice before while 
manipulating. It was 'scarcely as rough as the crepitus of a fracture, and it 
probably indicated that the cartilaginous margin of the acetabulum had been 
broken off. The limb was now brought down to the bed, and it was found to be 
in the same position as before reduction was attempted. Standing again over 
the patient, and placing my hand under the knee, I pulled upward, and the 
head resumed its place ; this time with a sudden jerk and with the same rough 
sensation. The limb was then placed in the extended position and secured by a 
long splint, which was not removed until the eleventh day. 

The facility with which the redislocation took place in the preceding case will 
sufficiently explain what happened in the following case on the tenth day after 
reduction, and on*account of which I was subsequently consulted : W. M., set. 18, 
was thrown from a wagon, dislocating his left femur into the ischiatic notch. 
Dr. Watson was consulted within three hours. Drs. Wood and Tafft were also 
present. Dr. Watson laid the patient on his back, and without anaesthetics re- 
duced the dislocation by manipulation. The bone was felt distinctly as it slipped 
into its place,' and the limb immediately resumed its natural position and length, 
as all the surgeons present affirm. He was soon out of the house on crutches, 
and on the eleventh day went in bathing. When he came out of the water he 
complained of his hip, and on the following day it was seen to be shortened. 
Subsequently it was examined by several surgeons, all of whom pronounced it 
dislocated. An attempt was then made to reduce the dislocation by Jarvis's 
adjuster, but without anaesthesia, as the patient refused to be rendered insen- 
sible. The attempt did not succeed. 

Lente relates a case in which, extension being employed, the cord was sud- 
denly cut while the limb was abducted and rotated outward, when the head of 
the femur left the ischiatic notch, and rose upon the dorsum ilii, assuming a 
position directly above the acetabulum, and below the anterior superior spinous 
process; and from which position it was subsequently, with great difficulty, 
returned to the socket. 1 

§ 3. Dislocation Downward and Forward into the Foramen Thyroideum. 

Syn. — "Downward into the foramen ovale;" Sir A. Cooper. "Downward into the ob- 
turator foramen ; " Lizars. " Downward and forward into the foramen obturatorium ; " 
B. Cooper. " Inward and downward into the oval hole : " Chelius. " Downward and for- 
ward into the foramen ovale ; " Pirrie. " Downward and inward : " Boyer. "Subpubic;" 
Gerdy. " Ischio-pubie ; " Malgaigne. 

Causes. — In order to produce this dislocation the limb must be, at 
the moment of the receipt of the injury, in a position of abduction. 
Perhaps most often it is occasioned by the fall of a heavy weight upon 
the back of the pelvis when the body is bent and the thighs spread 
asunder. 

Pathological Anatomy. — The capsule gives way upon the inner side 
especially; the round ligament is torn from its attachment, and the 
head of the femur, pressing forward and downward, finds a lodgement 
upon or against the obturator externus muscle, over the foramen thy- 
roideum. 

Symptoms. — The thigh is apparently lengthened from one to two 
inches, abducted and flexed, the body being also bent forward or flexed 
upon the thigh. The dislocated limb is advanced before the other, and 
the toes generally point directly forward, but they may incline either 

1 Lente, New York Journ. Med., November, 1850, p. 314. 



14 



DISLOCATIONS OF THE THIGH. 



outward or inward. The hip is flattened or depressed ; the long adduc- 
tors are felt tense upon the inside of the limb ; the trochanter major 
is less prominent than upon the opposite side ; and the head of the bone 



Fig. 460. 







Relations of the ilio-femoral ligament to the thyroid dislocation. (From Bigelow.) 

may sometimes be felt in its new position. The apparent lengthening of 
the limb alone is sufficient to distinguish this accident from a fracture of 
the neck. 

I have said " apparent " lengthening, because in the position in which the 
limb is found, it is difficult to make an accurate relative measurement of the two 
limbs ; and, indeed, Rivington, 1 of the London Hospital, could not in a case 
seen by him recognize any shortening, and in his experiments upon the cadaver 
he obtained a similar result. Holmes, 2 also, in a clinical lecture has stated that 
the lengthening is less marked in proportion as the abduction and outward rota- 
tion are greater. 

In some cases the position of the head of the femur may be recognized 
by a rectal examination ; or, in the case of females by a vaginal exami- 
nation. The flexion and abduction are due in some measure to the ten- 
sion of the psoas magnus and iliacus internus, and perhaps to a similar 
condition of other rotators and flexors ; but, according to Bigelow, the 
ilio-femoral ligament offers the chief resistance, and constitutes the chief 
impediment to the restoration of the bone. 

i Rivington, The Lancet. 1888, vol. ii. p. 321. 
2 Holmes, Med. Times and Gaz., Oct, 27, 1877. 






INTO THE FORAMEN THYROIDEUM, 



715 



W. Taylor 1 has reported an example of compound dislocation upon the fora- 
men ovale, in which reduction having been effected, it was, several weeks after 
the accident, followed by an abscess ; but from which he eventually recovered 
with a tolerably useful limb, but not without some ankylosis. 

Says Prof. Gunn : " In the dislocation downward and forward over the thyroid 
foramen, the anterior and inferior portion of the capsular ligament must be torn 
asunder for the escape of the head ; while from the extremely abducted state of 
the limb at the moment of the accident, the superior and posterior portion must 
be relaxed, and thus escape laceration. 



Fig. 461. 



Fig. 462. 





(Anterior view.) (Posterior view.) 

Dislocation into the foramen thyroideum. 

" Fig. 463 illustrates this dislocation and the condition of the ligament. It is 
seen that while the head of the femur occupies a position over the thyroid fora- 
men, and while the characteristic deformity of direction in the limb is present, 
viz., a moderately flexed and slightly abducted position, the superior and pos- 
terior untorn portion of the ligament is tense and holds the limb in its state of 
slight abduction. The flexed position of the limb is due mainly to the neces- 
sarily tense condition of the psoas magnus and iliacus muscles. The charac- 
teristic position of the limb in this dislocation is inconsistent with the integrity 
of the ilio-femoral portion of the capsular ligament. The greatly increased 
distance between the anterior inferior spinous process of the ilium and the ante- 
rior inter-trochanteric line of the femur cannot be accommodated by anything 
less than the rupture of this portion of the ligament. The head of the femur 
can be placed over the thyroid foramen in the intact state of this portion of the 
ligament; but in order to accomplish this, the femur must be flexed to the right 
angle with the longitude of the trunk. This is illustrated in Fig. 464. An 
examination of this figure, or of the specimen which I herewith exhibit, will 
fully warrant the positive statement, that in the downward and forward disloca- 
tion, if the limb is found in the position generally characteristic of this form of 



1 Taylor, The Lancet, 1881, vol. i. p. 732. 



716 



DISLOCATIONS OF THE THIGH 



the accident, the only untorn part of the capsule will be the upward and back- 
ward portion, as is illustrated in Fig. 464." 

Treatment.- — If we attempt to reduce by manipulation, it will be proper 
to follow the same rule which I have stated as applicable to dislocations 
backward, namely, to carry the limb, in the first instance, only in those 
directions in which it is found to move easily. Instead, therefore, of 
holding the leg in a position of adduction while the thigh is flexed upon 
the abdomen, it will be necessary to carry it up abducted ; and when 
the further progress of the knee toward the belly is arrested, the limb 
must be moved inward, and finally brought down adducted. When the 
knee is about opposite the pubes, or a little lower, in its descent, the 
femur should be gently rotated inward, for the purpose of directing the 
head toward the acetabulum. The reduction may also be sometimes 



Fig. 463. 



Fig. 464. 




Tense, untorn, upward and back- 
ward portion of capsular ligament 
in thyroid dislocation. (Gunn.) 



Illustrating what would be the degree of flexion 
in thyroid dislocation if the ilio-femoral portion of 
capsule remained untorn. (Gunn.) 



facilitated by lifting the head of the bone with the aid of a band passed 
under the upper portion of the thigh and over the shoulder of an assist- 
ant ; by giving to the shaft of the femur a slight rocking motion when it 
is about to enter the socket ; by pressing with the hand against the head 
of the bone, and by lifting at the knee. 

In one of the examples recorded by Markoe (Case 8), the reduction was accom- 
plished in the second attempt, by rotating the thigh inward just as the thigh 



INTO THE FORAMEN THYROIDEUM. 



717 



had descended below a right angle with the body, in the manner which I have 
above directed ; but in the second example (Case 9), a similar manoeuvre carried 
the head across into the ischiatic notch, while the reduction was finally accom- 
plished by rotating the thigh outward, and at the same moment adducting the 
limb strongly in a direction which carried the knee behind the other one. 
Markoe concludes that the latter mode is preferable, because it will throw the 
head of the bone a little upward as well as outward ; in which direction it will 
find a more gently inclined plane toward the socket. He admits, however, that 
both methods may accomplish the same result. But I am quite certain that the 
method by rotation of the shaft of the femur inward is in general most likely to 
succeed. In this way also, I think, both W. H. Van Buren, of New York, 1 and 
R. L. Brodie, of the U. S. Army, were successful ; 2 it is the method preferred by 
Bigelow, who also recognizes- the propriety of making outward rotation when 
inward rotation fails. " Flex the limb toward a perpendicular, and abduct it a 

Fig. 465. 




Reduction of thyroid dislocation by manipulation. (From Bigelow.) 

little to disengage the head of the bone ; then rotate the thigh strongly inward, 
adducting, and carrying the knee to the floor." It is especially worthy of notice 
that Anderson, so long ago as 1772, in the case already quoted, practised success- 
fully almost precisely the same method. In one example mentioned by Markoe 
(Case 7), it is pretty evident that the head of the femur was thrown into the 
ischiatic notch, by having flexed the thigh too much, so that " the knee touched 
the thorax." Indeed, it is questionable whether it will be best ever to bring the 
thigh much, if at all, above a right angle with the body, since any further 
flexion can only throw the head below the acetabulum, when in fact it is already 
too low. 

N. S., a painter, set. 33, fell from the second-story window upon a stone pave- 
ment, striking, as he believes upon the inside of his right knee. I saw him 
within an hour, and found the right tibia partially dislocated outward, the cor- 



1 "W. H. Van Buren, New York Med. Times, Jan. 1856, p. 127. 

2 R. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 93 ; from Charleston Med. Rev. 



718 



DISLOCATIONS OF THE THIGH. 



responding patella dislocated completely outward, and the right femur in the 
foramen thyroideum. His thigh was forcibly abducted, slightly rotated outward, 
and lengthened; by measurement made from the pelvis to the ankle, one inch 
and a half. The distance from the anterior superior spinous process to the fold 
of the groin was ten inches, but upon the sound side it was only eight and a 
half. The head of the femur could be distinctly felt in front, just under the 
pubes. Having administered chloroform, I first reduced the tibia and the 
patella, then seizing the thigh and leg, I flexed the thigh upon the body, carry- 
ing the limb upward abducted until it was nearly or quite at a right angle with 
the body, then inclining the knee slightly inward, I brought it down again, and 
when the thigh had nearly reached the bed, it fell into its socket with a dull 
flapping sensation. In every step of the procedure I followed the inclination of 
the limb. The recovery was rapid and complete. 

Sir Astley Cooper advises that the patient shall be placed upon his 
back, with his thighs separated as far as possible. The pulleys are to 
be made fast to a band drawn across the perineum of the dislocated limb, 



Fig. 46 




Sir Astley Cooper's mode of reducing a recent dislocation into the foramen thyroideum. 

in a direction upward and outward ; while a counter-band is to be passed 
around the pelvis through the band attached to the pulleys, and secured 
to a staple, or delivered to assistants placed upon the sound side of the 
body. When everything is arranged, the pulleys should be acted upon 
until the head of the femur is felt moving from the foramen thyroideum ; 
at this moment the surgeon must pass his hand behind the sound limb, 
and seizing upon the ankle of the dislocated limb, adduct it forcibly, thus 
converting the limb into a lever of the first order. 

If the dislocation has existed some time, he recommends that this 
procedure shall be varied by placing the patient upon his sound side 
instead of his back, and attaching the pulleys perpendicularly over the 



INTO THE FORAMEN THYROIDEUM. 719 

body. He especially cautions us not to flex the thigh during these 
manoeuvres, lest we force the head of the bone backward into the 
ischiatic notch, whence he affirms that it cannot afterward be returned 
to its socket ; but the experience of surgeons has since shown that this 
latter statement is incorrect, and that it may, in some cases, be afterward 
reduced, although it has fallen into the ischiatic notch. 

Mr. Liston says that this accident happened to himself while attempting to 
reduce a dislocation of only a few hours' standing, in a young and powerful man, 
but he had no difficulty in returning it to its first position. 1 

Brainard, of Chicago, reduced this dislocation, after both the compound pul- 
leys and Jarvis's adjuster had failed, by placing between the thighs a piece of 
wood wrapped about with several layers of a wadded quilt, and making use of 
this as a fulcrum upon which the thigh operated as a lever. The legs were sim- 
ply pressed togther, care being taken to keep the knees straight. 2 

The majority of surgeons of the present day place the limb in the 
flexed position before attempting to make traction. This may be done 
with the patient lying upon his back, and by the hands, alone or with 

Fig. 467. 




Effect of flexion upon the ilio-feinoral ligament in the thyroid dislocation. (From Bigelow.) 

pulleys, or the patient may be placed in a sitting posture, and the exten- 
sion made at right angles with the body. In all of these attempts to 
reduce by traction, measures must be taken to secure immobility to the 
pelvis. 

A man, 40 years of age, was admitted to Bellevue, having a dislocation of the 
left femur into the foramen thyroideum, which had been caused six hours be- 
fore. The limb was slightly abducted, and moderately flexed upon the pelvis, 
while he was lying upon the bed ; the position being that represented in Fig. 
457. There was a very marked depression in the situation of the trochanter 

1 Practical Surg., Amer. ed.. p. 93. 

2 Brainard, Northwestern Med. and Surg. Journ., 1852. 



720 DISLOCATIONS OF THE THIGH. 

major, and a fulness upon the inside of the limb, caused by the tension of the 
long adductors. The patient being under the influence of ether, the house sur- 
geon, Dr. E. D. Hudson, first attempted, under my instruction, to reduce the 
dislocation by manipulation, flexion, and rotation, with adduction ; but failing 
in this, a folded sheet was placed in the perineum corresponding to the dislo- 
cated limb, and committed to assistants, who were directed to pull upward and 
outward, the patient lying upon his right side, with his left thigh flexed to a 
right angle with his body. Dr. Hudson then passed a band under the upper 
part of the thigh and over his shoulders, lifting and pressing the knee forcibly 
inward at the same time. In a few seconds the reduction was accomplished. 

After the reduction is accomplished, the patient should be laid upon 
his back in bed, but instead of rotating the limb outward, as I have 
advised after a dislocation upon the dorsum ilii or into the ischiatic 
notch, it should be gently rotated inward, and the knees thus bound 
together. 

§ 4. Dislocations Upward and Forward upon the Pubes. 

Syn. — "Upward and forward on the horizontal branch of the share-bone;" Chelius. 
"Forward upon the pubes;" Pirrie. "On the body of the pubes, below the spine and 
transverse part of the bone;'' Skey. "Sur-pubic;" Gredy. " Ilio-pubic ;" Malgaigne. 

Causes. — This accident is generally occasioned by a fall upon the foot 
when the leg is thrown backward behind the centre of gravity ; as in a 
fall from the back end of a wagon, the foot being instinctively thrown 
backward in order to save the head ; or it may happen to a person who, 

Fig. 468. 




Specimen of dislocation upon the pubes, in St. Thomas's Hospital. (From Sir A. Cooper.) 

while walking, suddenly puts one foot into a hole, in consequence of which 
the pelvis advances, but the leg and upper part of the body incline for- 
cibly backward. Occasionally it has resulted from a fall upon the back 
of the pelvis, or from a severe blow received upon the same part. 



UPWARD AND FORWARD UPON THE PUBES. 



721 



A patient was admitted, under the care of Dr. Ure, into St. Mary's Hospital, 
London, with a dislocation upon the pubes occasioned by swimming. His 
account of it was, that when in the act of " striking out" he felt a catch in the 
right groin which he thought was cramp, and that he was able to walk after 
the accident, but with a good deal of difficulty. The examination proved that 
he had a dislocation upon the pubes, which Dr. Ure easily reduced. 1 

Pathological Anatomy. — Sir Astley Cooper dissected the hip of a 
person whose thigh had been dislocated upon the pubes for some time, 
the true nature of the accident not having been at first recognized. The 
acetabulum was partly filled by bone, and partly occupied by the tro- 
chanter major, both of which were 

much altered m their form. The FlG - 469 - 

capsular ligament was exten- 
sively torn, and the ligamentum 
teres broken off completely. The 
head and neck of the femur had 
torn up Poupart's ligament, so 
as to penetrate between it and 
the pubes, and lay underneath 
the iliacus internus and psoas 
muscles ; the anterior crural 
nerve was lying upon these mus- 
cles, over the neck of the femur. 
The head and neck were flattened 
and otherwise much changed in 
form. Upon the tubes a socket 
was formed for the neck of the 
thigh-bone, the head being above 
the level of the pubes. The 
femoral artery and vein were to 
the inner side (Fig. 468). 

The head of the femur may be 
found lying far forward upon the 
pubes (Figs. 472, 473), men- 
tioned below ; or it may lie fur- 
ther back, along the ilio-pubic 
margin, and rests below and in 
front of the anterior superior spi- 
nous process of the ilium. When 
the head rests directly below this 
process, the dislocation is consid- 
ered anomalous or irregular, and this form will be considered hereafter as 
the " subspinous " dislocation. 

In the accompanying drawing the relation of the ilio-femoral ligament 
of the head and neck of the femur is shown, when the head ascends 
moderately upon the pubes. The extreme displacement shown in the 
preceding illustration from Sir Astley Cooper is only possible where that 
portion of the capsule beneath the obturator internus is torn, and perhaps 
the obturator itself. According to Bigelow, the ilio-femoral ligament 




Dislocation upon the pubes below the ante- 
rior inferior spinous process of the ilium. 
(From Bigelow.) 



1 Medical News and Library, vol. xvi. p. 1, from Lond. Lancet, Nov. 7, 1857. 

46 



722 



DISLOCATIONS OF THE THIGH 



and the psoas magnus and iliacus internus are then the only remaining 
causes of e version. 

The femoral artery and vein are usually found upon the inner side of the 
head, but occasionally these vessels are in front of, and sometimes external to, 
the head. 

In a case related by Goldsmith, of Louisville, 1 where the femoral artery was 
situated in front of the head, and the dislocation remaining unreduced, at the 
end of two months a diffuse aneurism having formed, the primitive iliac was 
tied, and the patient died on the fifth day. The autopsy revealed an opening 
in the artery through which the head of the bone had passed until it lay within 
the cavity of the aneurism. 

Kronlein 2 reports a case of tearing of the femoral vein, in a case in which the 
leg had been thrown so violently backward that the heel touched the back of 
the shoulder. 

The weakest part of the anterior and upper portion of the capsule is, 
according to Prof. Gunn, " where it is not reinforced by the ilio-femoral 



Fig. 470. 



Fig. 471. 





External view of pubic dislocation. Pos- 
terior border of the great trochanter occupy- 
ing the acetabulum, pressing before it the 
posterior untorn half of capsule. (Gunn.) 



Anterior view ; showing continuity ot 
structure between the ilio-femoral and 
inferior border of posterior half of cap- 
sular ligament. (Gunn.) 



fibres. Through this the head escapes and rests in front of the body of 
the pubis, the posterior surface of the neck resting on the edge of the 
acetabulum, and the posterior border of the great trochanter settling 
somewhat into the socket. The portion of the capsule which remains 
untorn is the whole of the posterior half, and that part of the anterior 



i Goldsmith, Amer. Journ. Med. Fci., July, 1860, p. 30. 
2 Kronlein, Poinsot, op. cit., p. 1072. 



UPWARD AND FORWARD UPON THE PUBES. 



723 



half covered and strengthened by the reinforcing ilio-femoral fibres. 
The posterior half is forced down into the acetabulum by the trochanter 
major, which encroaches upon that cavity." Being thus pressed into 
the acetabulum, this portion becomes " moderately tense, but it does not 
exert much influence on this dislocation in any way. On the contrary, 
the ilio-femoral portion of the capsular ligament in front, with the pos- 
terior untorn portion from below the cervix, holds the dislocated head in 
its luxated position. In this dislocation, the ilio-femoral portion of the 



Fig. 472. 



Fig. 473. 





Uio-pectineal dislocation. (Bigelow.) 



Pubic dislocation. (Bigelow.) 



capsular ligament, by its continuity with the inferior border of the pos- 
terior untorn portion, possesses its usual potency. 

Symptoms. — The thigh is shortened sometimes, but not always ; ab- 
ducted, flexed slightly, rarely extended, and rotated outward. The 
trochanter major is carried back and lost, or nearly so, while the head 
of the bone may be generally felt like a round ball, lying upon or in 
front of the body of the pubes, in most cases outside of the femoral artery 
and vein. Larrey saw a patient in whom the femur was placed nearly 
at a right angle with the body ; and Physick once met with a dislocation 
upon the pubes " directly before the acetabulum," in which the limb was 
not at all shortened, but, on the contrary, a very little lengthened. 1 
Other surgeons have occasionally seen similar examples. 

The differential diagnosis between a fracture of the neck of the femur 
and this dislocation may be thus briefly stated. In the fracture there is 



Dorsey's Surgery, vol. i. p. 238, 1813. 



724 AMPUTATIONS OF THE THIGH. 

crepitus, mobility, slight eversion easily overcome, no abduction, the 
trochanter major rotates on a short radius, and the head of the bone 
cannot be felt. In this dislocation there is no crepitus, the limb is 
immobile, the eversion is extreme and not easily overcome, the thigh is 
often abducted, the trochanter major rotates upon a longer radius, and 
the head of the bone can generally be distinctly felt in its unnatural 
position. 

Prognosis. — Sir Astley Cooper remarks that although this accident 
is easy of detection, he has known three instances in which it was over- 
looked, and he cannot but regard such errors as evidence of great care- 
lessness on the part of the surgeon who is employed. The reduction has 
generally been accomplished, in recent cases, with no great difficulty ; 
and when not reduced, the patients have occasionally recovered with 
very useful limbs. 

Treatment. — From the several reported examples of dislocation upon 
the pubes reduced by manipulation, it would be difficult to draw T any 
practical conclusions, since the methods have differed so widely from 
each other. I shall mention only four, which may be found in our own 
journals. One of these has already been mentioned in connection with 
the history of this process, as a case of compound dislocation reduced by 
Dr. Ingalls, of Chelsea, Mass. ; and two examples were reported by E. 
J. Fountain, of Davenport, Iowa. Dr. Ingalls succeeded by carrying the 
limb into its greatest state of abduction, and rotating the thigh inward ; 
the replacement of the bone being aided also by pressing upon its head 
with his fingers thrust into the wound ; while Dr. Fountain succeeded 
equally in both of his cases, by an almost opposite mode of procedure, 
namely, by adducting the limb forcibly, rotating the thigh outward, and 
then flexing the thigh upon the body. 

The first of Dr. Fountain's cases occurred in June, 1854. The patient, an 
adult male, had fallen from the second story of a house to the ground, fracturing 
his lower jaw and dislocating his left hip. The limb was a trifle shortened and 
the foot strongly everted. The prominence of the trochanter was lessened, and 
the head of the bone could be felt upon the pubes. Assisted by Dr. Arnold, he 
reduced the limb in the following manner : The patient was laid on the floor, 
and placed completely under the influence of chloroform. The dislocated limb 
was then "seized by the foot and knee and rotated outward, the leg flexed and 
carried over the opposite knee and thigh, the heel kept well up, and the knee 
pressed down. This motion was continued by carrying the thigh over the sound 
one as high as the upper part of the middle third, the foot being kept firmly 
elevated. Then the limb was carried directly upward by elevating the knee, 
while the foot was held firm and steady, at the same time making gentle oscilla- 
tions by the knee, when the head of the bone suddenly dropped into its socket." 1 
The time occupied was not more than thirty seconds, and the force employed 
was very slight. 

The second case occurred on the 31st of October, 1855, in the person of an 
Irish laborer, the dislocation having been occasioned by falling with a horse 
while riding. The reduction was effected in about twenty seconds by the same 
process and without the aid of chloroform. 

Dr. Henry, of New York, successfully reduced a dislocation of the femur upon 
the pubes after twenty-six days. The first attempt, made October 23d, was un- 
successful. The second attempt was made October 29th. After repeated trials, 
by forced abduction and circumduction the head of the bone was thrown' into 

1 Fountain, New York Journ. Med., Jan. 1856, p. 69 et seq. 



UPWARD AND FORWARD UPON THE PUBES. 725 

the thyroid foramen, after which by abduction and extension it was conveyed 
into the acetabulum. He was dismissed cured in about three months. 1 

It is probable that no one method will succeed equally well in all 
cases ; but if the head of the bone, as in the case dissected by Sir Astley 
Cooper, has not only actually surmounted the pubes, but pushed itself 
fairly into the pelvis, then the limb ought to be abducted in the manner 
practised by Ingalls, and forcibly rotated outward, in order that the head 
may be thus lifted over the pubes ; and subsequently it should be flexed 
upon the body, adducted, and brought down. But in this manoeuvre we 
ought to be careful not to continue the rotation outward after the head 
of the femur has risen above the pubes, lest the head and neck should 
grasp, as it were, the psoas magnus and iliacus internus muscles, under- 
neath which they have been thrust. On the contrary, it will be neces- 
sary at this point to rotate the thigh again gently inward, which, by 
compelling the head to hug the front of the pubes, will enable it, while 
the flexion is, being made, to slide downward under these muscles toward 
the socket. If, however, the head of the bone has never risen upon the 
summit of the pubes, and is not actually engaged under the muscles 
which pass over it at this point, then the rotation outward will not be 
necessary in any part of the procedure. 

Barron Larrey has reported a case of dislocation "before the horizontal por- 
tion of the pubes," which he reduced "by suddenly raising with his shoulder 
the lower extremity of the femur, while with both hands he depressed the head 
of the bone." 2 This case Was attended with the unusual phenomenon of the 
thigh placed at a right angle with the body. 

Fig. 474. 



Reduction of dislocation upon the pubes, by extension. 

If reduction is attempted by extension, the patient ought to be laid on 
his back upon a table, with the dislocated limb falling off slightly from 
its side. The extending band, made fast above the knee, should then be 
secured to a staple in the line of the axis of the dislocated thigh and, of 
course, below the table ; while the counter-extending band, crossing under 

1 M. H. Henry, Amer. Journ. Med. Pci., Jan. 1875. 

- Larrey, London Med.-Cbir. Rev., Dec. 1820, p. 500; vol. i., first series, from Bulletin 
de la Fac. de Med., No. 1. 



726 DISLOCATIONS OF THE THIGH. 

the perineum, should be made fast in the same line, above the level of 
the table, and beyond the head of the patient. When extension is com- 
menced, and the head of the femur has begun to move, the reduction 
may sometimes be facilitated by lifting the upper part of the thigh with 
a jack-towel or a band passed under the thigh and over the neck of the 
surgeon, as I have recommended in both of the backward dislocations. 
It may be found advantageous, also, to flex and rotate the limb after 
extension has brought the head near the socket. 

§ 5. Anomalous or Irregular Dislocations. 1 

1. Dislocations directly Upward above the Margin of the Acetabulum, 
and below the Anterior Inferior Spinous Process. 

Syn. — " Sus-cotyloidiennes;" Malgaigne. "Subspinous."' " Sixth dislocation ;" Mutter 

Malgaigne affirms that the head, in this dislocation, is situated external 
to the anterior inferior spinous process, and about one inch below the 
anterior superior spinous process. 

It is in this position that the head of the femur is found in a specimen depos- 
ited in the museum of the Surgical Clinic of Bonn, by Kronlein. A new coty- 
loid cavity exists posterior to and on a level with the anterior inferior spinous 
process. 2 Blasius, of Halle, 3 says that he has been able to reproduce this dislo- 
cation upon the cadaver by forced extension (dorsal flexion), combined with 
adduction and outward rotation. 

The symptoms which characterize this accident are shortening of the 
limb, slight abduction and extension, with rotation upward. The ever- 
sion of the toes, together with the slight amount of shortening which has 
in general been observed, has led several times to the supposition that it 
was a fracture of the neck of the femur ; but the rigidity, and the position 
of the trochanter and head will usually render the diagnosis clear. 

The following was probably an example of the subspinous dislocation : B. M., 
set. 51, was thrown backward, in wrestling, in 1851. He felt a snap in the hip- 
joint, and found his thigh placed in a position of moderate adduction, so that 
he could get his knees together. He was able to walk, but not without limping. 
This condition continued three years, during which time he was constantly lame, 
and suffered much pain when walking. At the end of this period, when in the 
act of jumping from his wagon, his horses having become frightened, he felt a 
snap, and at once the complete functions of the joint were restored. He could 
walk without pain or halt, and he could bring his knees together. Three months 
later, while ascending a flight of steps, carrying a heavy weight, his foot slipped, 

1 Malgaigne, Traite des Frac. et des Lux., torn. ii. p. 869 et seq. Samuel Cooper, First 
Lines, vol. ii. p. 391. Pirrie's Surg., Amer. ed., 1852, p. 275. Skey's Surg., Amer. ed., 
1851, p. 110 et seq. Gibson's Surg., sixth American ed., vol. i. p. 386. Guy's Hospital Ee- 
ports, 1836, vol. i. pp. 79 and 97; 1838, vol. iii. p. 163. London Lancet, Lond. ed., 1848, 
vol. i. p. 184: 1840. vol. ii. p. 281; 1845, vol. i. p. 412; vol. ii. p. 159. London Med. Gaz., 
vol. xix. pp. 657 and 659 ; vol. x. p. 19 ; vol. xxxiii. p. 404. Medico-Chir. Trans., vol. xx. 
p. 112. Lente's paper on " Anomalous Dislocations of the Hip-joint," in New York Journ. 
Med. for Nov. 1850, p. 314 et seq. Philadelphia Med. Examiner. No. 51. Amer. Journ. 
Med. Sci., vol. xvi. p. 14. New York Med. and Phys. Journ., 1826, vol v. p. 597. New 
York Journ Med., Jan. I860, Dr. Shrady's case. Dislocation of the Hip, by Jacob J. Bige- 
low, M.D., 1869. 

2 Kronlein, Poinsot, op. cit., p. 1076. 

3 Blasius, Archiv fur klin. Chir., Bd. 16, Hft. 1, p. 207. 



ANOMALOUS DISLOCATIONS. 



727 



and the dislocation was reproduced, and in this condition it remained up to the 
period at which he consulted me, October, 1869. I found the thigh apparently 
elongated, but upon measurement it was found shortened half an inch. It was 
moderately abducted and rotated outward. All the motions of the joint were 
restricted. Although I feel very confident that the reduction could be again 
accomplished, the patient left without permitting me to make the attempt. 



Fig. 475. 




Subspinous dislocation ; the Y-lig- 
ament stretched the neck of the bone 
Avhich lies beneath it. (Bigelow.) 




Subspinous dislocation. Kronlein's specimen. 



P. C, set. 52, was admitted to Bellevue Hospital, with a dislocation of the 
right femur upward. He had fallen nine feet into a cellar. Dr. Erskine 
Mason, in whose ward the patient was received, called my attention to him a 
few hours after the injury was received. The limb was shortened one-fourth of 
an inch, as nearly as we could ascertain; strongly everted, or rotated outward, 
but hanging parallel with the other when he was standing, the right foot being 
a little in advance of the left. The head of the bone could be seen and felt below 
and to the inside of the anterior superior spinous process. The trochanter major 
was turned back, and there was a deep depression over it. The limb could be 
slightly adducted, but in all other directions it was immovable. After several 
ineffectual attempts at reduction, under ether, it was finally reduced by simple 
extension. 

M. M., set. 62, was admitted into the New York City Hospital with a disloca- 
tion of the left femur upward and forward upon the ilium. Dr. Charles M. 
Allin, one of the visiting surgeons, made some efforts at reduction on the same 
day, but failed. On the following day, in the presence of several medical gen- 
tlemen, including myself, Dr. Allin repeated his efforts more systematically, and 
was successful. Examining the limb while the patient was on his back, and 
under the influence of ether, preparatory to the operation, I found it shortened 
half an inch, strongly everted, and the thigh slightly flexed, but lying nearly 
parallel with the other. The thigh could be adducted quite freely, but in all 
other directions motion was more limited. With some difficulty it could be 
flexed to a right angle with the body. The head could be distinctly felt, but 
not seen, directly below the anterior superior spinous process ; and from this 



728 



DISLOCATIONS OF THE THIGH 



position it was occasionally moved, while manipulating, farther forward, but 
never fairly upon the pubes. The patient was a spare man, and not very mus- 
cular. The accident was caused by stumbling while ascending a flight of steps, 
and falling upon his knees and face. The skin over the spine of the tibia was 
much bruised and scratched. Dr. Allin made an attempt at reduction, 1st, by 
flexing the thigh at a right angle, and rotating outward forcibly. This was un- 
successful. 2d. By flexion and rotation inward. 3d. By extension in several 
directions by the hands, including vertical extension with the thigh flexed upon 
the body. 4th. Compound pulleys were attached to a lacque above the knee, and 
counter-extension was made by a folded sheet passed under the perineum, and 
secured to a staple ; the direction of extension being a little back from the line 
of the axis of the body, as recommended by Sir Astley Cooper. A jack-towel 
was placed under the upper part of the thigh, by which this part of the limb 
was lifted upward and outward ; a folded sheet also being carried across the pelvis 
to render it steady. The extension was now gradually increased, and the limb 
was from time to time rotated, and otherwise manipulated, so far as its condition 
of restraint would permit, until it seemed probable that this method was to fail 
also, the patient having now been under the influence of ether nearly an hour. 
5th. While the extension was extreme, the cord was cut by a quick stroke of an 
amputating-knife ; and immediately after, while the limb was lying paralyzed 
by the "shock/' Dr. Allin seized the thigh, raised the knee a little, rotating it 
inward, when the head fell easily into its socket. 1 

[Milner 2 reported the following case : A man, set. 20, fell heavily upon the 
great trochanter ; got up and suffered severe pain, but it soon passed off ; he 
continued his work four days. On examination both 
legs were parallel ; foot everted at an angle of 60° ; 
leg short one and one-eighth of an inch ; hip-joint 
absolutely fixed ; whole pelvis moves when thigh is 
flexed ; left trochanter much more prominent, and 
half an inch higher; distance from anterior superior 
spine and trochanter same on both sides as displace- 
ment backward compensates for upward luxation ; 
head of bone nowhere felt. After many efforts at 
reduction, it was effected by following Busch's form- 
ula, viz., abduct the thigh, rotate it somewhat out- 
ward, and carry it into hyper-extension, then rotate 
rapidly inward and place it straight. 

Barker reported a case of a boy, who fell at play 
with the right leg strongly abducted and somewhat 
flexed, and the left doubled up under him. He had 
little pain, but the deformity made his mother seek 
advice. Standing, the right thigh was strongly ab- 
ducted; and, to bring the foot to the ground, the 
pelvis was tilted; thigh slightly flexed and foot 
everted ; flattening in region of trochanter and obliter- 
ation of fold of nates ; thigh rigid, and could not be 
flexed, adducted, or extended. Reduction was effected 
as follows: drew the limb gently downward on its 
long axis, adducted, flexed and then circumducted, 
continuing downward traction, and rotated inward.} 



Fig. 477. 




Other surgeons have met with examples of 
the subspinous dislocation in which the patients 
have been able to walk quite well immediately 
after the accident. Bigelow supposes that in 
these cases the upper portion of the capsule has 
been completely torn from the margin of the acetabulum, and that the 
head has been permitted to ascend until it was arrested by the under 



Appearance of a subspinous 
dislocation. 



1 Brief report of same case, as a " suprapubic ; 
gery, April 15, 1877, p. 38. 

2 St. Barth. Hosp Bep., 1874. 



dislocation, in Archives of Clinical Sur- 



ANOMALOUS DISLOCATIONS, 



729 



surface of the ilio-femoral ligament at the point where it rises from the 
anterior inferior spinous process of the ilium. 

2. Dislocations directly Upward, between the Anterior Inferior and 
Anterior Superior Spinous Processes. 

Syn. — " Supraspinous :" more appropriately, " Intraspinous." 

Cummins reports a case which occurred in the practice of Gibson, of 
New Lanark, where the head of the bone was believed to be situated just 
above the anterior inferior spinous process and below the anterior supe- 
rior spinous process ; and also a little inward toward the pubes. The 
limb was shortened fully three inches ; the toes everted ; adduction and 
abduction were exceedingly painful and difficult, but flexion was more 
easily performed. The head of the bone could be felt in its new position, 
especially when the thigh was moved. At first it was supposed to be a 
fracture, but this error having been corrected, the surgeon proceeded to 
attempt reduction on the eleventh day. Extension was made by pulleys, 

Fig. 478. 




Supraspinous dislocation. (From Bigelow.) 

and when the head of the bone had descended to the margin of the 
cavity, Mr. Gibson lifted the upper end of the femur by means of a 
towel, at the same moment pressing the knee toward the opposite thigh, 
and forcibly rotating the limb inward ; by which means the reduction 
was accomplished. 1 

[The following case of this form of dislocation appeared in my clinic several 
years since : The patient was a lady about 30 years of age and the mother of 

1 Cummins, Guy's Hospital Beports, vol iii. p. 163, 1838. 



730 DISLOCATIONS OF THE THIGH. 

several children ; she was short and stout, and apparently in perfect health. In 
walking the right limb was planted firmly and maintained in a nearly straight 
position, while the left limb made a half circuit around it. In standing the 
right limb was found to be about two and one-half inches shorter, and the right 
foot was fixed in a position of strong eversion. On examination, the head of the 
right femur was readily discovered between the anterior inferior and anterior 
superior spinous processes. Abduction and adduction were moderately free, but 
flexion was slight. The lady gave the following history of her case, which was 
confirmed by her mother: Four years previously, while in confinement, her 
physician, a large, stout man, had hastened the process by early rupture of the 
membranes, urging her to make great efforts, and during each pain pressing 
with both hands very firmly upon her right knee. She. stated that at times the 
right thigh would be so flexed by his great pressure as to be forced violently 
against her body, causing acute pain at the hip. She suffered far more than in 
other confinements, but when it was over the limbs were placed side by side, 
and she was comfortable. Two or three days after, in attempting to change her 
position in bed, she was seized with violent pain in the right hip, and from that 
time she suffered almost constant pain in that hip for a year more. When she 
began to leave her bed, which she did not do for months, there was a gradual 
change going on in her right leg ; it gradually became shorter, the foot became 
more and more everted, and at length she noticed a hard tumor forming outside 
of the inferior spinous process. 

The case was clearly one of rupture of the capsule and primitive downward 
dislocation caused by the violent flexion and abduction of the thigh by the 
physician. Then followed a series of changes in the position of the head, caused 
by her daily voluntary efforts in walking and working, by which it passed 
upward between the acetabulum and anterior inferior spine, and finally became 
fixed between the two spines in a rude socket of its own.] 

Lente has seen the head of the femur in the same position as in the case 
reported by Cummins, not as a primitive dislocation, but consequent upon an 
attempt to reduce a dislocation into the ischiatic notch. The shortening was 
about two inches ; the limb very much rotated outward ; the rotundity of the 
affected hip greater than that of the other, and the trochanter major one inch 
farther removed from the anterior superior spinous process. The head of the 
bone could be felt distinctly in its new position. The reduction was effected 
finally with pulleys, by the aid of chloroform, and by rotation of the limb in 
various directions. 1 Morgan also reports a case in which the head of the femur 
was above the acetabulum, and a little to the outside of the ilio-pectineal emi- 
nence. 2 

Some of these dislocations have been reduced by manipulation alone, 
or by manipulation aided by pressure. The limb should be seized in 
the usual manner, at the knee and ankle, carried up toward the face, 
abducted, then rotated inward, gently adducted, and finally brought 
down again to the bed. At the moment when the rotation and adduc- 
tion commence, the head of the bone should be pressed toward the socket 
by the hands, and, if necessary, lifted a little over the margin of the ace- 
tabulum, by moderate extension at a right angle with the body. Others 
have been reduced easily by extension alone after a thorough trial of 
manipulation. 

1 Lente, New York Journ. of Med., Nov. 1850, p. 314. 

2 Pirrie's Surgery, p. 276. See, also, Phil. Med. Exam., No. 51, Mutter's paper. 



ANOMALOUS DISLOCATIONS. 



731 



3. Dislocations Upward upon the Dorsum Ilii, and near its Anterior 

Margin. 

Si/n. — "Anterior oblique;" Bigelow. 

Bigelow, who regards as irregular only those dislocations which are 
accompanied with a complete rupture of the ilio-femoral ligament, but 

Fig. 479. 




"Anterior oblique dislocation." (From Bigelow.) 

whose classification in that regard I am not fully prepared to adopt, has, 
nevertheless, given us the most intelligible and most probable explana- 
tion of the mechanism of these irregular upward dislocations, and of 
several other forms of irregular dislocations. According to this writer, 

Fig. 480. 




Mechanism of "anterior oblique dislocation." (From Bigelow.) 

the "anterior oblique dislocation," in which the limb is found greatly 
adducted, and at the same time strongly everted, is a regular dorsal dis- 
location, the head being advanced upon the dorsum to a point near the 



732 DISLOCATIONS OF THE THIGH. 

anterior margin of the ilium. If now the limb be brought down, the 
neck of the femur will be made to bear against the outer fibres of the 
ilio-femoral ligament, and as these gradually give way the head will 
become more and more hooked over the remaining fibres of the ligament, 
and above the inferior spinous process (" supraspinous ") ; or, continued 
efforts being made to straighten the limb, the ligament will give way 
entirely, and the femur will assume the position indicated by the dotted 
lines (Fig. 473). He states that "the anterior oblique dislocation may 
be reduced by inward circumduction of the extended limb across the 
symphysis, with a little eversion, if necessary, to disengage the head of 
the bone. Inward rotation then converts this into the common luxation 
upon the dorsum." 

4. Dislocations Downward and Backward upon the Posterior Part of 

the Body of the Ischium, between its Tuberosity and its Spine. 

J. C. set. 35, was admitted to the Pennsylvania Hospital, under the care of 
Dr. Hewson. The patient, a muscular man, had been crushed under a falling 
roof, and, as he thought, with his right thigh separated from his body. When 
received into the hospital, one hour after the accident, the right thigh was flexed 
upon the pelvis, and rested upon the left; the right leg was also flexed upon the 
thigh ; the knee was below its fellow, the toes turned inward, and the whole 
limb shortened at least one inch. The head of the bone could be felt distinctly 
resting upon that portion of the ischium which lies between the acetabulum, the 
tuberosity of the ischium, and the spine. On the following day the muscles of 
the patient having been sufficiently relaxed by suitable means, the pulleys were 
applied ; but, after a second attempt, some of the bands having given way sud- 
denly, the pulleys were removed, when it was found that the reduction had been 
accomplished, although neither the patient nor his attendants had noticed the 
return of the bone to its socket. For several days there was entire loss of sensi- 
bility and motion in the leg, owing, probably, to the pressure which had been 
made upon the sciatic nerve; but these symptoms gradually disappeared, and 
at the time when the case was reported, about two months after the accident, he 
was walking with crutches. 

Dr. Kirkbride, who reported this unusual case of dislocation, doubted whether 
the extension was necessary to the reduction, as the head of the bone was 
brought very near the margin of the acetabulum by lifting the thigh with a 
towel, and it probably afterward entered the socket as soon as the extension 
was relaxed. 1 Malgaigne has referred to several similar examples. 

5. Dislocations Downward and Backward into the Lesser or Lower 

Ischiatic Notch. 

Syn. — "Behind tuber ischii;" Gibson, S. Cooper. " Fifth dislocation;" Gibson. 

C. L., of Lubec, Mass., was riding a spirited horse, when the animal, being 
restive, suddenly reared and fell back on his rider in such a manner that the 
weight of the horse was received on the inside of the left thigh, Mr. L. having 
fallen on his back, a little inclined to the left side. The surgeon who was imme- 
diately called recognized it as a dislocation, and thought he had succeeded in 
reducing it ; but a day or two later it was seen by a second surgeon, who declared 
that it was still out of place, and repeated the attempt at reduction, but without 
success, as the result proved. Dr. John C. Warren, of Boston, was able to deter- 
mine, as he affirms, the precise character of the accident- The limb was elon- 
gated, contracted, and the head could be felt in its unnatural position. By 
advice of Dr. Warren he was taken to the Massachusetts General Hospital, and 

1 Kirkbride, Amer. Journ. Med. Sci., vol. xvi. p. 13. 



ANOMALOUS DISLOCATIONS. 733 

a persevering attempt was there made to reduce the bone, but with no better 
success than had attended the efforts previously made. 1 

Mr. Keate has reported a case produced in a very similar way by a horse 
having fallen backward with the rider into a deep and narrow ditch; but the 
position of the limb was somewhat extraordinary, considering that it was a dis- 
location backward, the whole limb being very much abducted and the toes being 
turned outward, as if the head of the bone was in front of the tuber ischii rather 
than behind it. The thigh and leg were much flexed, and the whole limb was 
shortened from three to three and a half inches. The head of the femur could 
be distinctly felt "inferior to the ischiatic notch and on a level with the tuber- 
osity of the ischium." In the first attempt at reduction the head of the bone 
was thrown into the foramen thyroideum, from which it was, however, after one 
or two more attempts by extension, and by lifting with a jack-towel, restored to 
the socket. Mr. Keate believes that the dislocation was originally into the fora- 
men ovale, but that in the struggles made by the patient to extricate himself it 
was thrown backward into the position in which he found it. 2 

Mr. Wormald has reported a primitive accident of the same kind occasioned 
by jumping from a third-story window. The patient died soon after, and at the 
autopsy the head of the femur was found under the outer edge of the glutseus 
maximus, projecting through the torn capsule opposite the upper part of the 
tuber ischii. The shaft of the femur lay across the pubes, and the limb was 
considerably shortened and turned inward. 3 

6. Dislocations directly Downward. 

Syn. — " Sous-cotylo'idiennes ;" Malgaigne. 

The following is one of several similar examples now upon record : 
A man, a?t. 50, was admitted into the London Hospital under the 
care of Mr. Luke. A dislocation of the left femur was easily diagnos- 
ticated, but the symptoms were peculiar, inasmuch as the limb was 
lengthened one inch, without either inversion or eversion ; yet the 
head of the bone could be easily felt, and was thought to be in the 
ischiatic notch. By manipular movements reduction was easily effected 
about an hour after the accident. The man subsequently died from 
the effects of broken ribs. At the autopsy, Mr. Forbes, the house- 
surgeon, before dissecting the parts, again dislocated the bone. This 
was done with ease, and it was clear that the original form of dislocation 
had been reproduced, as the bone could not be made to assume any other 
position. The head of the bone proved to be displaced neither into the 
ischiatic notch nor the tlryroid hole, but midway between the two, imme- 
diately beneath the lower border of the acetabulum. The gemellus 
inferior and the quadratus femoris had been torn, the ligamentum teres 
had been wholly detached, and there was a laceration in the lower part 
of the capsular ligament. 4 

Dr. Blackman, of Cincinnati, informs me that, in January, 1859, he reduced 
a subcotyloid, incomplete dislocation, in a man aet. 70, by manipulation, Dr. 
Judkins lifting the thigh upward and outward by means of a towel, while Dr. 
Blackman first flexed and then abducted the limb. 

1 New York Med. and Phys. Journ., vol. v. p. 597, 1826. Letter to the Hon. Isaac Parker, 
etc., by John C. Warren, 1826. North Amer. Med. Journ., vol. iii. p. 169. 

2 Amer. Journ. Med. Sci., vol. xvi. p. 226, 1835, from Lond. Med. Gaz., vol. x. p. 19. 

3 Wormald, London Med. Gaz., 1836. 

4 Luke, Med. News and Librarv, vol xvi. p. 34, March, 1858, from Med. Times and Gaz., 
Jan. 2, 1858. 



734 DISLOCATIONS OF THE THIGH. 



7. Dislocations Forward into the Perineum. 

Syn. — " Perineales ;" Malgaigne. " Luxations sur la branche ascendante de l'ischion ;" 
D'Amblard. " Inward on the ramus of the os pubis;" Skey. 

D'Amblard published an example of this accident in 1821, occasioned 
by a violent muscular exertion made by the patient in an effort to spring 
into his carriage, the symptoms attending which did not differ materially 
from those which were found to be present in the three following exam- 
ples, except that in the first case the toes were turned slightly inward, 
while in each of the other cases they were turned outward. 1 

Mr. E., set. 35, a calker by occupation. The injury was received while a* 
work under the bottom of a canal-boat, the boat being raised upon props three 
and a half feet long. The patient was standing very much bent forward, with 
his feet far apart, between which lay a piece of round timber one foot in diam- 
eter, when the props gave way, letting the whole weight of the boat upon him- 
self and his companions. One of the workmen was killed outright. On extri- 
cating Mr. E. from his situation, the left leg and thigh were found extended at 
a right angle with the body, the toes turned slightly inward, the natural form 
of the nates was lost, and the head of the femur could be felt distinctly moving, 
when the limb was rotated, in the perineum, behind the scrotum, and near the 
bulb of the urethra. For the purpose of reduction, the patient was laid on his 
back upon a table, and the pelvis made fast by a muslin band. Extension, ac- 
companied with moderate rotation, was then made in a direction outward and 
downward, bringing the head of the bone over the ascending ramus of the 
ischium, beyond which it was lying, into the foramen thyroideum ; and from this 
position the bone was replaced in the acetabulum, by carrying the dislocated 
limb forcibly across the opposite one. The patient soon recovered the use of 
the joint. 2 ■> 

J. B., an Irishman, set. 40, on entering the St. Louis Hospital, gave the following 
account of his accident, which had occurred six hours previously : He was engaged 
in excavating earth, and having undermined a bank, it unexpectedly fell upon his 
back while he was standing in a bent position, with his thighs stretched widely 
apart. The weight crushed him to the earth, breaking both bones of his right 
leg, the radius of the same side, and dislocating the left hip into the perineum. 
The thigh presented a peculiar appearance, being placed quite at a right angle 
with the body, but somewhat inclined forward. The part of the hip naturally 
occupied by the trochanter major presented a depression deep enough to receive 
the clenched fist ; while the head of the bone could be both seen and felt pro- 
jecting beneath the skin of the raphe in the perineum. Rotation of the limb, 
which was difficult and excessively painful, rendered the position of the head 
still more manifest. The patient had also retention of urine, occasioned prob- 
ably by the pressure of the femur upon the urethra. Having dressed the frac- 
tures, Dr. Pope placed the patient under the full influence of chloroform, and 
then proceeded to reduce the dislocated thigh; for which purpose "two loops 
were applied, interlocking each other in the groin, and, using the leg as a lever, 
extension, by means of the pulleys, was made transversely to the axis of the 
body. A steady force was kept up for a short time, and the thigh-bone glided 
into its socket with a snap that was heard by every attendant and patient in the 
large ward." 3 

A man, set. 22, was admitted to the Toronto Hospital, under the care of Dr. 
E. W. Hodder, having been injured by the fall of a bank of earth an hour 
before. The head of the right femur was found under the arch of the pubes, 

1 Malgaigne, op. cit., torn. ii. p. 876. 

a W. Parker, New York Med. Gaz.. 1841; N. Y. Journ. Med., March, 1852, p. 188. 
3 Pope, St. Louis Med. and Surg. Journ., July, 1850 ; N. Y. Journ. Med., March, 1852, 
p. 198. 






ANCIENT DISLOCATIONS OF THE FEMUR. 735 

the neck resting upon the ascending ramus. The thigh formed nearly a right 
angle with the body, being strongly abducted, and the toes were slightly everted. 
On the following day, the patient being under the influence of chloroform, ex- 
tension and counter-extension were employed in the direction of the axis of the 
femur, that is, nearly at right angles with the body, while, at the same moment, 
the upper portion of the femur was lifted by a round towel. By this manoeuvre 
the head of the bone was carried into the foramen thyroideum. The force was 
now applied in a direction " more upward and outward ; the ankle held by the 
assistant was drawn under the other and at the same time rotated." In a few 
minutes the complete reduction was accomplished. His recovery was steady, 
and three weeks later he was discharged, being able to walk very well with the 
aid of a cane. 1 



§ 6. Ancient Dislocations of the Femur. 

Sir Astley Cooper was of the opinion that three months after the acci- 
dent for the shoulder, and eight weeks from the hip, may be fixed as the 
period at which it would be imprudent to attempt to make the reduction, 
except in persons of extremely relaxed fibre or of advanced age. At 
the same time, he was fully aware that dislocations have been reduced at 
a more distant period than that mentioned ; but in many instances the 
reduction has been attended with evil results. 

Later surgeons do not seem always to have correctly understood this remark, 
or, if they have understood, they have not correctly represented ; since it has 
many times been affirmed of this surgeon, that he regarded reduction of the hip 
as impossible after eight weeks, and they have proceeded to cite examples which 
would prove that he was in error. But long before Sir Astley's day, Gockelius 
mentioned a case of reduction of the femur after six months, and Giulio Saliceto 
declared that he had reduced a similar dislocation after one year, 2 and Sir Ast- 
ley says that he is " fully aware " of the existence of such facts or statements ; 
yet with a knowledge of what has so frequently followed these attempts, he 
would not recommend the trial after eight weeks, except under the circum- 
stances by him stated; and notwithstanding the number of these reported 
successes has been considerably increased in our day, I suspect that Sir Astley's 
rule will continue to govern experienced and discreet surgeons. Certain examples 
which have recently been published of successful reduction after six months by 
manipulation, if sufficiently verified, would encourage a hope that the period 
might be greatly extended. 

The following case was published in the first edition of this treatise, but I 
regret to say that I am now unable to say from what source my information was 
then obtained, and communications addressed by me to gentlemen in Havana 
have failed to trace the case to its original source. A careful reading of the 
report must convey to the experienced surgeon a suspicion that it may not have 
been correctly diagnosticated, and that, if it was, its reduction may not have 
been thoroughly accomplished and permanently maintained. 

A Chinese boy, aged about sixteen years, arrived at Havana on the 4th of June, 
1856, suffering from a severe illness. When sufficiently recovered to rise upon 
his feet, it was ascertained that he had a dislocation of the left femur upon the 
dorsum ilii. The accident had occurred before leaving China, a period of more 
than six months. Deeming the use of anaesthetics improper, on account of the 
boy's feeble condition, these agents were not employed. Dr. Dupierris pro- 
ceeded as follows : The body being held by two assistants by means of two bands, 
one of which passed beneath the perineum, and the other under the axillae, 
traction was made upon the limb by two strong and intelligent assistants. The 

1 Hodder, British Amer. Journ., March, 1861. 

2 Malgaigne, op. cit , torn. ii. p. 185; from G-allicinium Medico-practicum, Ulm, 1700, 
p. 288. 



736 DISLOCATIONS OF THE THIGH. 

movement of the head of the bone, resulting from this manoeuvre, was very 
limited, even when the force was much increased ; and the excruciating pain, 
which the patient referred to the iliac region, compelled him to desist. The 
following day he concluded to attempt the reduction by flexion. The patient 
being placed upon his back, and the trunk of the body made steady by assist- 
ants, with the left hand he grasped the upper part of the leg, placed the right 
hand upon the head of the bone in the iliac fossa,, and then proceeded to flex 
the leg upon the thigh, and the thigh upon the pelvis. By this movement the 
great gluteal muscle was relaxed, and the head of the bone advanced, while 
with the right hand he directed the latter toward the cotyloid cavity. As soon 
as he judged the head to be immediately above the centre of the socket, he 
extended the leg, the thigh remaining flexed at a right angle ; and then using the 
limb as a lever, he rotated it from within outward, and at the same time extended 
it by making a movement of circumduction in a similar direction. When, by 
these procedures, the limb was brought near to its opposite fellow, a snap 
audible to the assistants indicated the return of the head of the bone to its 
natural position ; a fact which was further substantiated by the establishment 
of the original length and form of the member and the subsidence of the pain. 

The case reported by Guyenot, 1 of a woman twenty-two years of age, in 
which Cabanis is said to have accomplished reduction after the dislocation 
had existed two years, was probably an example of chronic hip disease. 

Nor is it proper to accept of the accidental reduction of the femur, reported 
to Sir Astley Cooper 2 by Mr. Cornish, as a well-authenticated case. 

Dr. Lewis A. Sayre, in a paper read before the American Medical Association, 
has reported a case of pathological dislocation, into the ischiatic notch, of nine 
months' standing. 3 

The patient, Lieut.-Col. William A. Bullit, was wounded in battle, May 9, 
1864, in two places, the first ball entering five inches below the anterior superior 
spinous process of the ilium, and remaining. More than five months after the 
injury he, for the first time, turned from his back to his side, and in doing so he 
felt "a slipping" of the caput femoris. This occurred almost daily for two 
weeks, when, dislocation being recognized, Dr. McDermott, assisted by Drs. 
Coolidge and Goldsmith, U. S. A., attempted to reduce it under ether, but failed. 
" In the latter part of February, 1865, four months after dislocation," another 
attempt was made to reduce it, under chloroform. The fact that this was not a 
traumatic dislocation, dating from the period of the original injury, is thus con- 
firmed by Dr. Sayre, for it was already more than nine months since he had 
been wounded, but the dislocation had taken place only four months previous. 
At this time the attempt at reduction was made by Professor Cook, assisted by 
Drs. Force, Cox, Gait, and Garvin, all of Louisville, Ky. This attempt failed 
also. July 20, 1865, Dr. Sayre, in the presence of several gentlemen, including 
myself, the patient being under chloroform, forcibly broke up some adhesions 
and brought the limb, which was flexed upon the pelvis, down to a position 
nearly but not quite parallel with the other, and there secured it with a weight 
and pulley. There was no claim at the time, so far as I know, that a restora- 
tion of the bone to its socket had been effected. Some months later I saw this 
gentleman standing with a high heel under the boot corresponding to the lame 
leg, and I was then informed by Dr. Sayre, in reply to my inquiry, that the dis- 
location was not reduced, but that, as t could see, the position of the limb was 
greatly improved. In Dr. Sayre's report of the case he does not state when the 
dislocation was reduced, and certainly it was not reduced in my presence ; and 
I have no reason to suppose that it was subsequently. 

Dr. George E. Post, Missionary in Syria, and a Professor in the Protestant 
College, at Beirut, has reported a remarkable case of dislocation of both hips in 
a native girl, thirteen years old, " the result of a vis a tergo, applied six months 
previous" to her admission to the hospital. The force applied to her back 
caused her to fall forward, with a ''twisting of the trunk to the right, and the 

1 Mem. de l'Academie Royal de Chirurgie de Paris, torn, cinquieme, p, 803. 

2 Fir Astley Cooper, Frac. and Dis., 2d Lond. ed., p. 101. 

3 Sayre, Case of Luxation of Femur into Ischiatic Notch, of nine months' standing, 
Reduced by Manipulation, Trans. Amer. Med. Assoc, 1866, p. 263. 



ANCIENT DISLOCATIONS OF THE FEMUR. 737 

lower extremities to the left." She was admitted Jan. 20, 1877. At this time it 
was ascertained that she had a dislocation not only of the left femur, but that 
there was a fracture of the neck also on the same side; the head had become 
necrosed, and there was a sinus communicating with the head as it lay upon the 
dorsum ilii. An incision was made, and the dead bone was removed. The 
ankylosed knee and thigh were then straightened by briseinent force, the restora- 
tion being accompanied with a good deal of laceration. The left lower extremity 
was then committed to an assistant, while the requisite manipulations were 
undertaken to reduce the dislocation of the right hip. This was effected with- 
out pulleys, adding another to the many proofs that bone-setting is a matter of 
address and attention to anatomical relations rather than to force.'' The patient 
recovered after a prolonged confinement, and at the last accounts was able to 
walk with crutches, the function of the right limb being fully restored, and the 
left being shortened four and a half inches. 1 

It is unnecessary to say that the mode of production of this double disloca- 
tion was extraordinary, and that the facility with which the right hip was reduced 
at the end of six months was equally extraordinary ; and that for these reasons 
the distinguished operator owed it both to himself and to the profession to sup- 
ply a more complete history of the case, symptoms, and treatment than he has 
given. In so far as the cause and the mode of reduction are concerned, I have 
given my readers all that the report contains. 

The case reported by Bigelow, of reduction after three months, must be re- 
jected also as a traumatic dislocation. Dr. Bigelow says himself that it was 
" perhaps connected with hip disease,'' as there was evidence of disease in the 
joint for some time prior to the accident which was supposed to have caused the 
dislocation, and its subsequent existence was demonstrated by sinuses which 
formed and opened in the groin. He had also had for a long time disease of the 
bone near the ankle. 2 

Dr. Brown's case of reduction of ancient dislocation of the femur in a child 
eight years old, cannot be considered in this connection, inasmuch as he states 
that the dislocation was probably caused by chronic rheumatic arthritis. 3 

In the accompanying table I have inserted such cases as have up to 
the present moment the best claim to be regarded as actual reductions of 
traumatic hip-joint dislocations after a period of eight weeks. Some of 
them, however remarkable they may seem to be, there exists now no 
satisfactory means of verifying or of disproving. Others, even among 
those reported by my contemporaries, are so briefly and imperfectly re- 
ported that they do not seem to me thoroughly established — certainly 
not by that sort of testimony which science demands where unusual and 
extraordinary facts are recorded. While estimating the relative value of 
the several methods of reduction, I have cited several examples of frac- 
ture of the neck of the femur in the attempt to reduce old dislocations. 
In some cases the results have been much more serious. 

A man, 29 years old, was received at La Pitie, Paris, on the 13th of May, 1868, 
with dislocation of the hip of seven months' standing. M. Broca attempted to 
reduce it, using a force of 480 lbs. No reduction was obtained, and the patient 
insisted upon leaving the hospital five days afterward. A fortnight then elapsed, 
when he presented himself at another hospital, with the hip enormously swollen, 
and died the next day of peritonitis. The autopsy showed that the head of the 
bone lay in the ischiatic notch, that it was held firmly by bundles of the torn 
capsule, and that the cotyloid cavity was much shrunk. Pus was found in the 

1 Post, Med. Record, May 11, 1878, p. 366. 

2 Bigelow, Disloc. and Frac. of Hip, 1869, p. 111. 

3 Spontaneous Dislocation on Dorsum Ilii ; Reduction after several months. By Francis 
Brown, M.D., etc. A pamphlet. Boston Med. and Surg. Journ., Sept. 29, 1870. 



738 



DISLOCATIONS OF THE THIGH. 



Table of Traumatic Dislocations of the Hip, reduced after 

eight weeks. 



No. 


Operator. 


Age of 
patient. 


Time after 
disloca- 
tion. 


Form of 
dislocation. 


Method of 
reduction. 


Reference. 






Years. 








1 


S. Nott, 


33 


56 days. 


On dorsum 
ilii. 


Extension. 


Sir Astley Cooper, Disloc. 
and Frac, etc., 2d Lond. 
ed., p. 50. . 


2 


Despres, 


48 


66 days. 


Foramen 

ovale. 


Extension, 
with anaes- 
thesia. 


Bull. fcoc. Chir., 1879, p. 142. 


3 


A. Crosby, 




68 days. 




Extension, 


Trans. Amer. Med. Assoc, 








with anaes- 


vol. iii. p. 356. An. 1850. 












thesia. 




4 


Pollock, 


72 


72 days. 


Ischiatic 
notch. 


Extension, 
with anaes- 
thesia. 


The Lancet, 1880, vol. ii. p. 
130 


5 


Breschet, 




72 days. 






Brown, Boston Med. and 












. Surg. Journal, Sept. 29, 
1870. 
Dupuytren on Diseases and 


6 


Dupuytren, 


23 


78 days. 


Dorsum 


Extension. 










ilii. 




Injuries of Bones. Lond. 
ed., 1847, p. 373. 


7 


Kimball, 




3 mos. 






Northwestern Med. and 














Surg. Journ., June, 1870. 


8 


Doutrelepont, 


7 


3 mos. 


Dorsum 
ilii. 


Extension. 


Berliner klinische Wochen- 
schrift, 1876, No. 31, p. 
455. 


9 


Bayer, 




3 mos. 


Foramen 
ovale. 


Manipula- 
tion. 


Prager med. Woch., 1880, 
No. 30. (Poinsot.) 


10 


Blanc, 




3 mos. 






Journ. des Conn. Med. Chir., 














1870, No 2. 


11 


Dupuytren, 


25 


99 days. 


Dorsum 
ilii. 


Extension. 


Dupuytren, op. cit., p. 375. 


12 


W. L. Atlee, 




4 mos. 


Extension, 


Trans. Amer. Med. Assoc, 












with anaes- 


vol. iii. p. 357, An. 1850. 












thesia. 




13 


Williams, 


8 


5 mos. 


Probably 

in ischiatic 

notch. 


Anaesthesia. 


The Lancet, vol. i. p. 665, 
An. 1862. 


14 


Bigelow, 


7 


5 mos. 


Dorsum 
ilii. 


Manipula- 
tion. 


The Lancet, 1878, vol. i. p. 
86. 


15 


MacGee, 




5£ mos. 




Manipula- 
tion. 


American Journ. Med. Sci., 










January, 1871. 


16 


Gockelius, 




6 mos. 






Gallicinium Med. - pract. . 
Ulm, 1700, p. 288. 














17 


Dupierris, 


16 


6 mos. 


Dorsum 

ilii. 


Manipula- 
tion. 




18 


Blackman, 




6 mos. 






Western Lancet, April, 














1856, p. 253. 


19 


Peltavy, 


34 


6 mos. 


Foramen 
ovale. 


Manipula- 
tion. 


Wiener med. Wochenschrift, 
1873, No. 47. 


20 


Bigelow, 


27 


8 mos. 


Dorsum 
ilii. 


Manipula- 
tion. 


Bigelow on Dis. and Fract. 
of Hip, 1869, p. 55. 


21 


Carron du Vil- 
lars, 




8 mos. 


Foramen 
ovale. 


Extension. 


Malgaigne, op. cit. vol. ii. 
p. 868. 


22 


Smyth, 


27 


9 mos. 


Dorsum 

* ilii. 


Manipula- 
tion, with 
anaesthesia. 


New Orleans Journ. Med., 
Jan. 1, 1869, p. 71. 


23 


Saliceto, 




1 year. 






Malgaigne, Fract. and Dis., 












Paris ed., 1855, vol. ii. 














p. 185. 



ANCIENT DISLOCATIONS OF THE FEMUR. 739 

capsule, in the iliac fossa, in the articular cavities, and had found its way into 
the peritoneum, through the obturator foramen. 1 

The following case seems deserving of mention, for the reason that it is the 
first, so far as I am aware, in which an attempt has been made to reduce the 
dislocation after a subcutaneous division of the capsule : T. J., set. 28, of Utica, 
N. Y., was sent to me by Dr. Jenkins, in January, 1869, having a dislocation of 
his left femur upward and backward upon the dorsum ilii. His account of the 
case was, that seven months before he was thrown in wrestling ; a surgeon was 
called on the following day, and finding a dislocation, he placed him under the 
influence of an anaesthetic, and, as he supposed, reduced the dislocation by 
mauipulation. The case did not come under the notice of Dr. Jenkins until a 
few weeks before he was sent to me, and although the character of the accident 
was recognized, no attempts were made at reduction. I found the limb rotated 
inward, adducted, and shortened two inches. Before the class of medical 
students at Bellevue, assisted by Drs. Sayre, Crosby, Howard, and others, I 
made an attempt, January 29th, to break up the adhesions and reduce the dislo- 
cation, the patient being fully under the influence of ether. We were able to 
move the limb quite freely in various directions ; but after a trial of nearly an 
hour, we abandoned the attempt, having failed to accomplish reduction. 

A few days later I applied extension, by means of adhesive plaster and a cord, 
with a weight of twenty pounds. This was continued unremittingly until Feb- 
ruary the 24th, when he was again placed under the influence of ether before 
the class. Assisted by Drs. Stephen Smith, Howard, Cross, and others, attempts 
were made to reduce the bone by manipulation, but without success. Believing 
now that the untorn portion of the capsule, and particularly the ilio-femoral 
ligament, constituted the chief obstacle to the reduction, I introduced a long, 
firm, but narrow bistoury, which I had had made for the purpose, just above the 
trochanter major, carrying its point inward until it touched the neck at the base 
of the trochanter. From this point, the edge of the knife being directed toward 
the head of the bone, I swept the point of the knife slowly along until the head 
was distinctly felt, the point touching the neck apparently in its whole length. 
This was accomplished without enlarging the external opening. While the 
incision was being made the limb was kept rotated outward, and abducted as 
much as was possible, and it was felt to yield distinctly, so that both rotation 
outward and abduction were more complete afterward than before. I then 
divided also the tensor vagina? femoris ; and now the attempts at reduction were 
repeated, both by manipulation and extension, but without success. 

The result of this attempt to reduce the dislocation by division of the ilio- 
femoral ligament, although unsuccessful, encourages a hope that it may some- 
times succeed ; and I shall not hesitate to repeat the experiment, if a favorable 
opportunity is presented. 

In 1878, Dr. MacCormack, of London, 2 practised subcutaneous tenotomy of 
the muscles for the purpose of reducing a dislocation into the foramen ovale, 
which had existed two years. The patient was 19 years old. The section ot 
the muscles gave no result ; and Dr. MacCormak then exposed, by a free 
external incision, the articulation ; and finding the socket was nearly obliterated 
he resected the head of the femur, and obtained a satisfactory result. In 1876, 
Volkmann, 3 also, practised resection of the head of the femur, after having ex- 
posed the joint and divided the muscles extensively, in the hope that in this 
way he might effect the reduction ; but in which case, as in the case of Mac- 
Cormack, the reduction was even then found impracticable. The patient was a 
man, set. 51, who had a dislocation into the perineum of about three months' 
standing, and which Volkmann had tried in vain to reduce by other methods. 
The head of the femur was found upon the dorsum of the ilium, to which point 
it had been carried by the previous manipulations. The head and neck were 
resected at a point below the trochanter, and the operation resulted in a com- 
plete recovery, and in giving to the patient a tolerably useful limb. M. Polail- 

1 New York Med. Record, Dec. 16, 1868. 

2 MacCormack, St. Thomas's Hosp. Rep., vol. ix. p. 101. 

3 Volkmann, Ranke, Berliner klin. Wochensclirift, 1877, No. 25, p. 357. 



740 DISLOCATIONS OF THE THIGH. 

Ion 1 reports the case of a man, set. 46, who had a dislocation upon the dorsum 
ilii. The dislocation had occurred more than six weeks before ; and although 
repeated attempts were made to reduce the dislocation, commencing on the day 
following the accident, and by various methods, it still remained unreduced ; 
but the head had been transferred from the dorsum to the foramen ovale, in 
which position it lay when M. Polaillon proceeded, with antiseptic precautions, 
to open the joint, and to sever the ligamentous and muscular attachments which 
prevented the return of the bone to its socket. Reduction having been effected, 
the wound was closed. The patient died on the fourth day, his death being 
caused, as it would appear, by septicemic infection. 

[Resection of the head of the femur, with proper use of antiseptic remedies, is 
now a very safe operation, and the surgeon who employs them intelligently need 
not hesitate to perform this operation when he deems it necessary. Nor would 
it be an improper procedure in obstinate cases to open the joint freely, divide 
obstructing tissues, and replace the head, as was done by Lister in old disloca- 
tions of the head of the humerus.] 

§ 7. Partial Dislocations of the Femur. 

Malgaigne declares that certain experiments made upon the cadaver 
led him, at one time, to the conclusion that all primitive dislocations of 
the femur were incomplete, and that the old complete dislocations found 
in autopsies have become so consecutively. Later observations have 
taught him to correct this error, yet he still finds " incomplete backward 
dislocations quite common, and incomplete dislocations in all the other 
directions much more common." I have more than once found occasion 
to call in question the accuracy of Malgaigne's views in relation to partial 
dislocations, the relative frequency of which, as traumatic accidents, he 
seems constantly disposed to exaggerate greatly. I cannot see the pro- 
priety of calling those cases partial dislocations, in which the head of the 
bone has fairly left the cotyloid cavity, and mounted upon its margin, 
even if it remains in this position without tearing the capsule ; since the 
articular surfaces are now as completely separated as if the capsule had 
given way, and the head of the bone had escaped through the laceration. 
It is in fact a complete dislocation. But I doubt very much whether the 
head of the bone ever rests upon the margin of the acetabulum without 
tearing the capsule, unless it has previously undergone certain patho- 
logical changes, such as I have already described ; at least I cannot 
hesitate to reject all those examples in which the head of the femur is 
supposed to rest upon the upper or outer margin of the acetabulum ; and 
if I permit myself to speak of incomplete dislocations at all in this con- 
nection, I shall reserve the term for those rare cases in which the head 
of the femur becomes engaged in the cotyloid notch, after breaking down 
the fibrous band which, in the natural state, is continuous with the rim 
of the acetabulum. 

Of this form of dislocation, I think I have met with two examples ; one ot 
which was in the person of a boy, whose thigh was reduced accidentally by his 
father ; and the other occurred in a boy 15 years of age, residing at that time in 
Rutland, Vermont. He was brought to me on the 28th of May, 1842, by Dr. 
Haynes, of Rutland, at which time the dislocation had existed five years. His 
account of himself was that in walking upon a slippery floor, his left leg slid 
outward and backward in such a manner that when he fell it was fairly doubled 

1 Polaillon, Bull. Soc deCliir. de Paris, 1883, Seance du 31 Jan. 



COXO-FEMORAL DISLOCATIONS. 741 

under his back. On the tenth day following the accident he began to walk with 
some help, and he has continued to walk ever since, but with a manifest halt. 
Three months after the injury was received, it was first seen by several surgeons, 
who pronounced it a dislocation, and attempted reduction without mechanical 
aid, but were unsuccessful. When the young man was brought to me, the limb 
was neither lengthened nor shortened, but the thigh was forcibly abducted and 
rotated outward. It could not be flexed nor greatly extended. The head of 
the femur could be distinctly felt, as it lay anterior to the socket, but not suffi- 
ciently far forward to rest upon the foramen thyroideum. 

J. C. Warren, of Boston, has reported a similar example in a child 6 years 
old, who was brought, April 21, 1841, to the Massachusetts General Hospital. 
Dr. Hale, who saw the lad at the end of two weeks, thought it a dislocation, but 
it had been treated by another surgeon as a case of hip-disease. The dislocation 
had now existed eight or ten weeks. The limb was a little lengthened, abducted, 
turned outward, and advanced in front of the body, with very slight motion ot 
either flexion or extension, and almost no tenderness about the joint. Dr. 
Warren, also, was able to feel indistinctly the head of the bone " immediately 
external to, and in contact with, the insertion of the triceps and gracilis mus- 
cles." An attempt was made by manual extension and manipulation to accom- 
plish the reduction, but without success. 1 

It is probable that both the above cases, which I have described at length, 
were examples of partial dislocations; yet I cannot conceal from others a doubt 
which I actually entertain whether they were not, after all, only examples of 
hip-joint disease, arrested after having wrought certain slight pathological 
changes in the joint and the tissues adjacent. If, however, they were not 
examples of incomplete dislocation of the hip-joint, then I question whether any 
such cases have ever occurred as simple traumatic accidents. 

§ 8. Coxo-femoral Dislocations, complicated with Fracture of the 

Femur. 

Such complications are exceedingly rare, but it will not do to deny 
their possibility ; although in some of the cases reported, the testimony 
is so incomplete as to leave a doubt whether the surgeons have not erred 
in their diagnosis. 

James Douglas has reported a case of dislocation upon the pubes, complicated 
with a fracture of the neck of the femur, the actual condition of which was 
verified by an autopsy ; the patient having died twelve years after the injury 
was received. The head of the femur still remained above the pubes, and was 
in no way connected with its neck or shaft. The upper end of the femur pro- 
jected in the groin, lying upon the inside of the femoral artery and vein. Many 
other curious pathological changes had also occurred. 2 

The well-authenticated examples of reduction of the dislocation, where 
the femur was broken also, are still more rare ; and several of the 
recorded examples which my researches have discovered, need additional 
confirmation. 

John Bloxham, of Newport, in the Isle of Wight, claims to have reduced a 
dislocation of the femur on the pubes, which was accompanied with a fracture 
of the thigh a little above its middle. On the seventh or eighth day after the 
accident, "the patient was laid on his back upon the bed, and kept in that 
position by means of a sheet passed across the pelvis and fastened to the bed- 
stead ; another sheet was also passed over the left groin, and secured in a similar 
manner. The dislocated and fractured limb was then inclosed in splints, one of 

1 Warren, Boston Med. and Surg. Journ., vol. xxiv. p. 220. 

2 Amer. Journ. of Med. Sci., vol. xxxiii. p. 455, from Lond. and Edin. Month. Journ. 
of Med. Sci., Dec. 1843. 



742 DISLOCATIONS OF THE THIGH. 

which extended up the back of the thigh as far as the tuberosity of the ischium. 
Pulleys, which were secured to a staple in the ceiling, placed at the distance of 
a foot to the right of a point vertical to the patient's navel, were then attached 
to a bandage fastened around the splints as high up as possible. The foot was 
raised with the knee extended, so as to bring the limb nearly to a right angle 
with the line of the tackle, when by drawing gradually on the cord, in the course 
of about ten or fifteen minutes the head of the bone was rendered movable, and 
was brought considerably more forward. I then began to press on the head of 
the bone, so as to push it downward, while the pulleys held it partially disen- 
gaged from the pelvis. In a few minutes the head of the bone passed over the 
ridge of the os pubis, and I then directed the foot to be raised a little higher, 
which by putting the glutei muscles more upon the stretch was calculated to 
render them more efficient in drawing the bone into its proper place. By this 
manoeuvre, the head of the bone was drawn backward, and on the foot being 
more elevated and the cord slackened, it continued to recede from my fingers 
till the trochanter major made its appearance in the natural situation, and the 
reduction was found to be perfectly complete. Lest the head of the bone should 
slip backward on the dorsum ilii, I directed an assistant to apply firm pressure 
during the latter part of the process, above and behind the acetabulum. The 
apparatus was then removed, the thigh bound up in short splints, and the patient 
laid upon a double-inclined plane. No symptoms of inflammation appeared 
afterward about the joint. Passive motion was employed at the end of a week, 
and occasionally repeated during the whole reparatory process." 1 Without 
intending to question the accuracy of the statements in this case, which, in the 
main, seem to bear the marks of credibility, I must express my surprise that so 
little difficulty was experienced in the reduction if the femur was actually 
broken, no more, indeed, than is usually experienced when the bone is not 
broken ; and that Mr. Bloxham was able to employ safely passive motion at the 
end of a week. 

Charles ThornhilP relates a case of fracture of the femur through its upper 
third, in a man set. 40, with dislocation into the ischiatic notch ; which disloca- 
tion, he assures us, was reduced at the end of six weeks. But it is much more 
probable that, instead of reducing a dislocation, he refractured the bone. During 
more than one hour and a half, aided by pulleys, tractions and manipulations 
were made in almost every direction. The upper part of the thigh was lifted 
with all the strength of one man by means of a jack-towel; it was violently 
rotated, adducted, and abducted. Both the perineal and the knee band gave 
way, from the excess of the force employed ; and, finally, the head of the femur 
resumed its place with an audible crash, after which the "limb was of nearly 
equal length with the other ;■" but there remained an " immense deposit" around 
the acetabulum. 3 

Malgaigne says that M. Eteve found a man with a dislocation of his left thigh 
backward, a fracture near its middle, a penetrating wound of the knee, and a 
fracture of the fibula in the same leg. Without delay he proceeded to reduce 
the dislocation by directing two assistants to support the body, three to support 
the leg, and two more to make extension from a towel tied not very tightly 
around the thigh above the fracture. The leg was then extended upon the 
thigh and the thigh flexed upon the pelvis until it was at a right angle with the 
body ; and after a gradual extension had been made in this direction, M. Eteve 
pushed with all his strength the head of the bone into its socket. Of which 
case Malgaigne justly remarks that the "extension'' practised by the surgeon 
was only imaginary. 4 If the reduction was accomplished at all, it was by man- 
ipulation and pressure. 

Finally, Markoe relates the case of a boy set. 8, who was admitted into the 
New York City Hospital, on the 29th of June, 1853, with a compound fracture 
of the right thigh, a simple fracture of the left, and a dislocation of the head 
of the right femur upward and backward upon the dorsum ilii. When placed 

1 Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1833. 

2 London Medical Gazette for July, 1836. 

3 Araer. Journ. Med. Sci , vol.xxv. p. 218. 

4 Malgaigne, op. cit., torn. ii. p. 206,- from Gazette Med., 1838, p. 757. 



DISLOCATIONS OF THE FEMUE. 743 

upon the bed, the right limb lay obliquely across the abdomen of the boy, with 
the foot resting against the axilla of the left side. "The house-surgeon to 
whose care the case fell on admission, took the injured limb in his hands very 
carefully, carried it over the abdomen to the right side, and then abducted it 
and brought it down toward the straight position," during which procedure the 
head of the bone is supposed to have resumed its place in the socket. 1 Such is 
the account furnished of the symptoms and treatment of this extraordinary 
case ; too meagre, certainly, to entitle it to much confidence, or to permit us to 
draw from it any practical inferences. 

I have been unable to find any other examples of fracture of the 
femur complicated with dislocation ; and, rejecting at least Mr. Thorn- 
hill's case as altogether incredible, the proper conclusion w T ould be, that 
reduction is sometimes possible in recent cases, if the surgeon will resort 
promptly, before swelling and muscular contractions have taken place, to 
manipulation combined with pressure upon the head of the bone. In- 
deed, it is probable that pressure alone is the means upon which the 
success will finally depend. Richet says that he has several times dis- 
located the femur in the cadaver ; and then having sawn off the head 
so as to represent a fracture, he has always been able to push the head 
of the bone easily into its socket. 2 By seizing the moment then when 
the patient is laboring under the shock, or by placing him completely 
under the influence of an anaesthetic, no resistance will be offered by the 
muscles any more than in the cadaver, and the reduction may, perhaps, 
be easily effected. I have no confidence that anything can be accom- 
plished by extension; nor do I think it will be best to wait until the 
femur has united, since such delay will probably render the reduction 
impossible. 

§ 9. Voluntary or Spontaneous Dislocations of the Femur. 

Examples in which persons, having suffered no disease of the hip- 
joint, have been able voluntarily to dislocate the femur, have, from time 
to time, been recorded, but I am not aware that any dissections have 
ever been made in these cases. I shall, therefore, not attempt any Ex- 
planation of the facts, but simply record them as matters of curious 
interest, and for the purpose of inducing others to make of them a sub- 
ject of investigation. 

Malgaigne remarks that " certain persons, without having suffered from any 
injury or disease of the joint, have the singular faculty of dislocating and re- 
ducing the femur voluntarily. Portal saw an example in the person of the 
Abbe of Saint-Benoit. Humbert mentions a surgeon near Troyes, who dislo- 
cated the femur up and down, and reduced it by the simple act of the muscles, 
without the aid of his hands. He reports at the same time, the curious history 
of a person endowed with the same power, who after a quarrel produced the 
dislocation, and then claimed damages, attributing the accident to the violence 
of his adversary." The same author speaks of cases reported by Coulson, Solly, 
and Stanley, and the one hereafter to be mentioned alluded to by Sir Astley 
Cooper, making in all seven cases. It does not appear, Malgaigne adds, that 

1 New York Journ. Med., Jan. 1855, p. 30. 

2 New York Journ Med., March, 1854, p. 293; from Bullet, de Thcr. 



744 DISLOCATIONS OF THE THIGH. 

" this laxity impairs the functions of the limb ; it is nevertheless a subject which 
demands to be better studied." 1 

Sir Astley Cooper says, " I have received from Mr. Brindley, surgeon, of Wink 
Hill, an account of a dislocation of the os fernoris, which the patient is able to 
produce and reduce when he chooses. The man is fifty years of age." 2 

Samuel Cooper speaks of this matter briefly as follows : " There are instances 
recorded of persons who could dislocate their thigh-bone spontaneously, and 
afterward replace it again without assistance. A gentleman, who attended my 
lectures, informed me of a person so circumstanced, and related some of the 
particulars to me. I suppose that, in such cases, there must be an unusual re- 
laxation of the synovial membrane, a rupture of the ligamentum teres, and 
perhaps an imperfect state of the acetabulum." 3 

A case is related in an inaugural essay, by Dr. Lewis, of North Carolina, who 
graduated at the University of Pennsylvania in the spring of 1841."* 

Dr. Bigelow has seen two cases, and reports a third from Prof. E. M. Moore, 
of Eochester. In the first of these the hip was at first dislocated by an accident ; 
and in a few hours it was reduced by manipulation. Eight days after the acci- 
dent, in attempting to walk, it was again partially dislocated, when the patient 
himself replaced it by pushing against it with the hand, and pressing with the 
other against the knee. Since then the man has been able to dislocate the bone 
backward upon the edge of the socket by muscular action, and to reduce it by 
throwing the leg out sideways. In the second case seen by Bigelow, '' the 
phenomena are much like those just described." Dr. Bigelow regards them 
both as subluxations, and speaking of the first case, he says the limb " exhibits 
slight flexion, shortening, and inversion." Prof. Moore's case (Figs. 481, 482), 
is described as follows : J. B. Parker, private soldier, U. S. V., was skirmishing 
up a hill, May 13, 1864, and sprang suddenly back to avoid the gun of a com- 
rade in advance. His left foot became entangled, and his weight dislocated the 
hip. He felt the injury, and supposed it out of joint. Some comrades put it in, 
and he immediately resumed his skirmishing, and marched seven miles, from 
10 A. m. to 6 p. m. He rested at night, and went on duty the next day, sharp- 
shooting and crawling all day. He continued this kind of duty nine days, and 
subsequently was on duty in other ways, and did not enter a hospital until the 
fifteenth day after the accident. When the case was reported to Dr. Bigelow, 
the man could dislocate the hip at any time by pressing the foot on the floor, to 
fix it firmly, contracting the adductors, and throwing out the pelvis, when the 
head "suddenly leaves the acetabulum, and goes on the dorsum." There is a 
slight inversion while the limb remains in this position. Dr. Bigelow thinks 
that this is also a subluxation. 5 

The following case was reported to me in 1865, by Dr. Forrest, of Portland, 
Maine, to whom the man presented himself as a "substitute," while Dr. Forrest 
was in the the service of the U. S. Army. The application was rejected : W. 
G. Gliddon, set. 37, farmer, says that he has been able to dislocate and replace 
the femur at the left hip-joint since he was a boy. It is not the result of any 
injury or disease, so far as he knows. He is in good health, and his muscular 
development is complete. He accomplishes the dislocation by throwing the 
weight of his body upon the left leg, and then contracting certain muscles about 
the hip. The reduction is generally more difficult than the dislocation, some- 
times requiring the aid of his hand. When the head of the bone is out, there 
is a marked projection above and behind the trochanter major, apparently caused 
by the pressure of the head in this situation ; the limb is very slightly if at all 
everted ; while out of place it causes pain ; and after a few repetitions the pain 
becomes so great as to compel him to desist. The limb was not measured while 
it was dislocated. When the limb is in position he does not walk lame." 

1 Humbert, Essai sur less lux. spontanees du femur, 1835, p. 35. From Malgaigne, op. 
cit., vol. ii. p. 883. He also refers to Gaz. des Hopitaux, 1841, p. 104. 

2 Brindley, Sir Astley Cooper on Disloe. and Frac Preface to 2d Lond. ed., 1823. 

3 Samuel Cooper, First Lines. New York ed., 1844, vol. ii. p. 385. 
1 Gibson's Surgery, 6tb ed., An. 1841, vol. i. p. 387. 

5 Moore, Bigelow. Disloe. and Fractures of the Hip, by Henry J. Bigelow, 1869, p. 112. 



DISLOCATION'S OF THE FEMUR. 



745 



Dr. Maurice Perrin 1 brought before the Surgical Society of Paris, in 1859, a 
man aged 22 years, who when 10 years old had suffered a dislocation of the 
right hip in consequence of a fall from a horse, in which his leg was caught in 
the harness, and his body suspended in a position of forced adduction. On the 
following dav it was reduced. Two or three months later it was reproduced by 
a slight misstep. At a later period he was found to be able to dislocate and 
reduce the dislocation at will. When presented to the Surgical Society this fact 
was verified, and admitted by Chassaignac, Marjolm, Morel-Lavallee, and many 
others who were present. 



Fig. 431, 



Fig. 482. 





Voluntary subluxation upon the dorsum ilii. Case of Parker. (From Bigelow and Moore.) 

The following case came under my personal observation : Dr. William G-. S., 
set. 24, received an injury on the outside of the right knee, in February, 1862, 
from the kick of a horse. There was no apparent injury of the hip. On the 
fourteenth day after the accident he rode forty miles on horseback, which was 
followed by some stiffness in the right hip. Two weeks later, in mounting his 
horse, he felt something slip in the hip-joint. From that day until this, a period 
of four years, he has been able to reproduce the same slipping voluntarily, and 
which phenomenon I recognize as a dislocation upward and backward. I have 
examined him more than once, and he has dislocated and reduced the disloca- 
tion in my presence repeatedly. Planting his right foot firmly upon the floor a 
little in advance of the left, with his toes turned out, he throws his weight upon 
the right leg by carrying his pelvis well over to the right, and then contracts 
powerfully the gluteal muscles. Instantly the head leaves the socket, and seems 
to mount upon the dorsum; the trochanter major becomes rotated inward, caus- 
ing a slight inward rotation of the leg and foot. He can do the same when 
lying on his back, but not with the same ease. Reduction is accomplished with- 
out change of position, but by what precise manoeuvre I have not determined. 
The reduction is more quiet, and less sudden, apparently, than the dislocation. 



1 Perrin, Gaz. des Hop., 185y, p, 367. 



746 DISLOCATIONS OF THE THIGH. 

Both manoeuvres sre accompanied with some pain. He is not lame, nor does 
the dislocation take place without his volition. I have seen one case, also, 
which, although pathological in character, was nevertheless caused by an early 
iniury, and as such may properly be noticed in this connection. 

Dr. O. Gillett, set. 65 (1867), of Western ville, Oneida Co., N. Y., was injured 
in his left hip-joint when 16 years old, by lifting a heavy weight. He felt at 
the moment something give way in the joint, and he, has been lame ever since; 
at first he was quite lame, but after a time the soreness about the joint dimin- 
ished, and up to within about three years the lameness was chiefly due to a lack 
of development in the limb. Since then the joint has again become tender, and 
during the last nine months he has been able to throw the head of the bone 
out of the socket, backward and upward. Indeed, the bone is dislocated when- 
ever he sits down, and resumes its place again when he stands up. It is quite 
apparent that the upper and outer margin of the acetabulum is partly absorbed ; 
and probably, also, the head and neck of the femur are in some measure de- 
formed and absorbed. The dislocation is apparently incomplete ; and while it 
exists the thigh is abducted and slightly rotated outward. This abduction and 
outward rotation do not properly belong to a dislocation upon the dorsum of the 
ilium ; but as the condition of the joint and of the adjacent muscles is abnormal, 
they will not require to be explained. 

Deininger 1 relates the case of a retired soldier, who stated to him that when 7 
years old he met with an accident which caused, as was believed, a dislocation 
of his thigh backward. The dislocation was not reduced ; an abscess formed ; 
and at the end of fourteen weeks a spontaneous reduction ensued. After a time 
the patient began to observe a slipping of the joint, and when examined by 
Deininger the head of the femur was at each step dislocated backward, with the 
characteristic noise, but was again immediately restored to its normal position 
by muscular contraction alone. 

Karpinski 2 reports the case of a man who had dislocated his left hip when 16 
years old. Five years later, when seen by Karpinski, he was able to dislocate 
the femur upon the dorsum ilii by resting the weight of his body upon the left 
foot, and then turning his body to the left. Reduction' was effected by muscular 
contraction alone. 

In some respects the most remarkable example which has come to my 
knowledge is that of Charles H. Warren, the celebrated contortionist and 
acrobat. Having myself made a careful personal examination of the man, 
and having observed that he does actually subluxate other limbs than the 
thigh, it has seemed to me that it would throw light upon this somewhat 
obscure class of cases if I w T ere to give his history briefly, and describe in 
detail all the phenomena observed by me. My examination of him was 
made in 1870, when he was thirty-one years old. 

Mr. Warren was born in Schuylersville, Saratoga Co., New York, in 1848. 
His parents were healthy, and neither of the parents nor either of the five 
children, except Charles, possessed his peculiar muscular development or power 
of dislocating the bones. His maternal grandfather is said to have possessed a 
similar power, but in a much more limited degree. In his own case it was first 
noticed in his infancy, soon after he began to run about, that he would suddenly 
fall while running across the floor; and it was soon ascertained that he had 
been tripped up by the sudden displacement of his hip-joint, but the fall would 
restore it to place and he would get up and again run about. This is his own 
account of his case at this early period of life, and it may or may not be correct, 
as I am not informed that any medical man was ever consulted. His statement, 
however, finds a confirmation in the fact that an infant son of Mr. Warren, now 
dead, had the same peculiarity. He has also a little daughter, now living, in 
whom the same phenomenon, so far as the accidental dislocation of the hip- 

1 Deininger, Deutsche Militar-Artzl. Zeitschrift, iii. 2, p. 632, 1874. 

2 Karpinski, Idem, ii. 3, 1873, p. 157. (Poinsot.) 



DISLOCATIONS OF THE FEMUR. 747 

joint is concerned, is manifested. He has had no other children, and his wife is 
a healthy and well-formed woman. In his own case this tendency to accidental 
and involuntary dislocation of the hip-joint only lasted two or three years after 
he began to run about. Since then, it only occurs by an act of volition and 
under the powerful contraction of the muscles. It is not even apt to occur during 
his performance of gymnastic and contortion feats. As a boy, Warren ran about 
as other children and at five years went to school, but when eight years of age 
he left home and joined a travelling circus. At eighteen he began to work at 
the trade of car-making, but soon returned to the circus. 

Mr. Warren informs me that Walter Wentworth, a professional contortionist, 
now about forty-five years of age, and weighing perhaps 115 pounds, is probably 
more flexible than himself, but possesses rather less muscular power, yet he is 
very strong. John Santiago de Gibinois and George Mankin are probably as 
strong as himself; Lister, of the New York circus, now dead, was probably 
superior to anyone who has ever lived as a contortionist. The latter died at the 
age of forty-eight, and practised successfully his profession to the last days of 
his life. Yet not one of these men had the power of dislocating his bones which 
Warren possesses. It is clear, therefore, that we ascribe Warren's peculiar 
power in this respect to a congenital abnormity, namely, a great capacity and 
lengthening of the capsular structures, united with later muscular development 
from exercise. Warren is rather above the average height, slender, and well 
proportioned. 

I have called attention to these historical details, because they seem to 
illustrate — first, that Warren had a congenital relaxation of the ligaments 
and capsules of the joints ; and second, that his prodigious muscular 
development was the result of early and long-continued muscular exer- 
cise ; while the daily practice of contortion maintained the ligaments and 
capsules in their original abnormal condition. There is, therefore, in this 
case a combination of anatomical conditions rarely met with, namely : a 
relaxation of one class of structures or tissues, and an unusual power of 
action and contraction in another. We often see persons who have con- 
genital or acquired (pathological) relaxation of the articular ligaments, 
but this is associated in most cases with muscular weakness. So also 
there are frequent examples of great muscular power, the result of exer- 
cise, but the joints are compact also. None of them have the power of 
dislocating their bones by muscular action. The following are the results 
of my examination of. Warren's voluntary dislocations. 

Inferior Maxilla; Partial Dislocation Forward. — This is accom- 
plished probably by the action of the external pterygoid muscles. There 
is nothing worthy of special note in this, inasmuch as the ability to dis- 
place the condyle to this extent is not very unusual. The condyle re- 
sumes its place the moment the action of the muscle ceases. 

Clavicle ; No Displacement. — He has no power to displace the clavicle 
at either articulation. 

Scapula ; Displacement of Lower Angle. — This displacement is very 
remarkable, the lower angle of the scapula being lifted upward and out- 
ward until it lies nearly on a level with the top of the shoulder, and is 
made to project far backward. We are enabled here to study carefully 
the mechanism of this displacement, an example of which is every now 
and then reported in the journals asa" dislocation " of the scapula. It 
has been ascribed variously to a partial paralysis of the latissimus dorsi, 
in consequence of which the somewhat feeble hold which it has upon the 
inferior angle of the scapula is relaxed, and it is unable to retain the 



748 DISLOCATIONS OF THE THIGH. 

angle in its place ; to a detachment of this muscle from the angle in con- 
sequence of some violence ; to paralysis of the serratus major anticus ; 
and by one writer, to paralysis of the rhomboid muscles. In the case of 
Warren, it is apparent that it is accomplished solely by the action of the 
rhomboideus major, which muscle he has the ability to call into vigorous 
activity, while he suspends the action of the rhomboideus minor, the ser- 
ratus magnus, the latissimus dorsi and other muscles. We can even trace 
the fibres of the rhomboideus major as it lies in a state of contraction 
underneath the trapezius. When this muscle ceases to contract, the angle 
falls to its place spontaneously. 

It is probable that as we see it presented occasionally in other persons, 
it is due most often to a paralysis of the serratus major anticus ; possibly 
sometimes to a loss of power in the latissimus, and even occasionally to 
a disruption of the attachment of the latissimus ; but it is impossible 
that it should be due to a paralysis of either of the rhomboids, as has 
been suggested. Of course I exclude from consideration, now, all those 
examples of scapular projections which are due to spinal distortions, and 
which are purely mechanical, and have therefore nothing in common with 
this case. 

Head of the Humerus ; Subglenoid Subluxation. — By the action, 
apparently, of the latissimus dorsi, aided, perhaps, by the lower fibres of 
the pectoralis major, Warren displaces the head of the humerus down- 
ward, until it rests upon the lower margin of the glenoid cavity, causing 
a very marked depression under the acromion process, and increasing the 
length of the arm, as measured from this process, about one inch. He 
soon becomes weary of holding it in this position, and then when he 
relaxes the muscles, the head rises to its socket without noise or sensa- 
tion. His ability to perform this feat is equal in the two arms. 

Elbow-joint. — The elbow-joint admits of a slight increase of lateral 
motion above what is usual, and the backward movement, or extension, 
is greater than is usual with adults ; but he has no power to cause either 
a dislocation or subluxation at this joint. 

Wrist-joint; Backward, Forward, and Lateral Subluxation. — By 
the action of the muscles alone he displaces the carpal bones backward 
or forward, causing in each case a partial dislocation. He cannot, how- 
ever, cause a lateral dislocation without first grasping the wrist with the 
opposite hand — the wrist being grasped firmly by its radial and ulnar 
margins — when, by the action of the muscles, the carpus is thrown fully 
half an inch to either side. When the carpus is thrown to the radial 
side, the hand falls to the ulnar side ; and the reverse happens when the 
carpus is thrown to the ulnar side. When the muscles are relaxed, the 
carpus resumes its position spontaneously, and without sound or sensa- 
tion. 

Phalangeal Articulations ; Subluxations. — He is able to subluxate all 
the articulations of his fingers, including the thumb. The subluxations 
backward and forward are effected by muscular action, but the lateral 
dislocation only by the help of the other hand. 

Hip ; Apparently Complete Dislocation upon the Dorsum Ilii. — It is 
in the hip that the greatest scientific and surgical interest of this case 
centres. After a careful study of the phenomena accompanying certain 



DISLOCATIONS OF THE FEMUR. 749 

motions of the hip-joint in the person of Warren, I have felt compelled 
to accept of the theory that he causes a true and complete dislocation 
upon the dorsum of the ilium. We notice that while the patient is stand- 
ing nude, his form is perfect, except that both feet turn out a little more 
than is usual with others. With a moderate effort of the muscles the 
head of the bone seems to move in its socket, and to be carried upward 
and backward upon the dorsum ilii. The change of position occurs 
suddenly, and is accompanied with a sensation to the hand as of a bone 
slipping suddenly into its socket — a sort of heavy thud. When he has 
dislocated his right leg, he stands upon his left leg, the right being lifted 
from the floor, the thigh a little flexed upon the body, the leg flexed 
upon the thigh, with the toes turned a little in. He says, that know- 
ing that it ought to turn in a little more to represent the appearance 
which the limb usually presents in this dislocation, he sometimes, when 
exhibiting himself, turns it in more ; but this is the position, only 
slightly turned in, which it naturally takes. Looking for the trochanter 
major, we find that it has been carried upw T ard and backward full two 
inches. The head of the bone we are unable to find It is very diffi- 
cult to make a comparative measurement of the two limbs when one is 
thus displaced, but, so far as I can determine, the right limb is shortened 
at least one inch, probably more. Warren repeated the dislocation 
several times ; the bone always returning quietly to its place after each 
displacement, without any sound or sensation like that which accom- 
panied its displacement. The same experiment was made with the oppo- 
site thigh, and with the same results. Finally, he was laid upon the 
floor, upon a blanket, and he produced the dislocations equally, but 
apparently with little more muscular effort. 

There seem to be but two possible explanations of the phenomena 
presented in the case of the femur : either they are produced by the 
trochanter rotating outward, and pressing firmly against the anterior 
margin of the glutseus maximus, until suddenly it becomes disengaged 
and slips under this muscle, while the head of the bone remains in its 
socket ; or, there is a veritable dislocation of the head of the bone. 

In favor of the first supposition it may be stated again, that when the 
displacement in the case of Mr. Warren has occurred, the trochanter 
major is removed backward and upward full two inches; it remains as 
prominent as it was before, and the head cannot be found ; while in the 
usual dislocation upon the dorsum the trochanter turns forward, and is 
less prominent than it was before ; and the head of the bone may usually 
be felt when there is no swelling. How then could this be a dislocation ? 
Plainly only by supposing that there was such an abnormity of the joint 
— an almost total absence of the rim of the acetabulum in that direction — 
and perhaps such a broadening of the head, and shortening of the neck, 
as would permit the head, neck, and trochanter to be drawn up and back 
by the gluteal muscles, without changing the relations of the line of their 
common axis to the outer face of the pelvis ; that is, without any inward 
tilting of the trochanter. This would assume the existence of anatomical 
conditions that are not proven, but only deemed possible. 

If the limb is actually shortened, however, there must be a dislocation, 
and I think it is ; but inasmuch as the accuracy of any measurements 



750 DISLOCATIONS OF THE THIGH. 

under these circumstances might be fairly questioned, we shall for the 
moment dismiss this argument also. 

There now remains only this important fact, that while the trochanter 
major is carried back, the toes are no longer very much turned outward, 
as they were before the displacement was made ; nor do they point 
forward, but actually a little inward. So that in fact there is about as 
much inward rotation of the foot as we could have required to indicate 
an outward dislocation. But it is plainly impossible that the head of 
the femur should remain in its socket, while the trochanter is rotated 
outward two inches, and the knee, foot, and toes not accompany this 
outward rotation. Certainly it is impossible that the whole lower portion 
of the limb should rotate inward, as it actually does, while the trochanter 
is strongly rotated outward. These considerations, it seems to me, must 
exclude the supposition that there is here only a rotation of the trochanter 
outward, and a consequent muscular displacement. 

Whatever difficulties there may be in the way of supposing that this 
is a dislocation, they are not insuperable if we assume the existence of 
some abnormity in the construction of the joint and of the neck. It 
is possible even, that what we believe to be the trochanter moved back 
is actually the head of the bone, and that it is the trochanter which is 
lost ; for the change of position occurs so suddenly that neither by the 
sight, nor with the hands placed upon the trochanter, can we follow the 
change of position. I only discover, after a sudden commotion, that 
there is no longer a projection where the trochanter was felt, and which 
I marked with a pencil in order not to be deceived ; and that there is a 
projection which resembles it precisely, so far as we can determine, two 
inches further back and upward. Possibly, I say, this new projection is 
really the head, somewhat changed from its normal form ; but I do not 
think so. Perhaps nothing but an autopsy can determine this and other 
points connected with the case. 

Knee-joint ; Rotation and Subluxation. — Mr. Warren has no power 
to displace the knee-joint by muscular action ; but seizing the leg while 
it is flexed, he can rotate the tibia laterally very freely, and cause the 
head of the tibia to project beyond the line of the articulation half an 
inch or more. 

Patella. — He has no more power to displace this bone. 

Ankle-joint — With his hands he can abduct and adduct this joint 
almost to a right angle with the leg. 

Tarsal Joints. — By the aid of his hands he can imitate the extremes 
of varus and valgus. 

Phalanges of the Toes. — They are loose, but not so loose in their 
articulations as the phalanges of the fingers. 

Adams, 1 of Glasgow, describes the case of a young man who, when 20 years 
of age, in trying to imitate an acrobat dislocated his thigh, which he reduced 
without assistance. After this he found himself able to dislocate either hip at 
pleasure. In order to accomplish this he raised the foot of the limb which he 
wished to dislocate, until only the toes touched the floor, and then suddenly 
flexed and adducted the limb. On ceasing the muscular contraction the bone 
returned spontaneously to its socket. This patient, who was examined three 

1 Adams, Glasgow Med. Journ., Oct. 1882, vol. viii. No. 4. 



DISLOCATIONS OF THE PATELLA OUTWAED. 751 

years after the original accident, was able also to displace voluntarily the inferior 
maxilla. 

Chassaignac 1 furnishes 'an account of a vaulting mountebank, who had a 
congenital dislocation of both hips upon the iliac fossae, which he was able 
voluntarily to convert into ischiatic dislocations. 



CHAPTER XVIII. 

DISLOCATIONS OF THE PATELLA. 
§ 1. Dislocations of the Patella Outward. 

Causes. — In the majority of cases this dislocation has been occasioned 
by muscular action ; and especially is this liable to occur in persons whs 
are knock-kneed, or whose external condyles have not the usual promi- 
nence anteriorly. It may be caused by suddenly twisting the thigh 
inward while the weight of the body rests upon the foot, and the leg is 
thus kept turned outward ; or by falling with the knee turned inward 
and the foot outward. Occasionally it is the result of a blow received 
upon the inside, or upon the front and inner margin of the patella. In 
some persons there seems to exist a preternatural laxity of the ligamentum 
patellae or of the tendon of the quadriceps extensor, which exposes the 
subject to this accident from very trifling causes. 

Fergusson says he has known it to be occasioned by a child's stepping upon 
the knee of a person lying in bed ; and Skey says he has seen two cases which 
occurred spontaneously during sleep. B. Cooper has seen a young lady who 
frequently dislocated her patella outward by merely striking her toe against the 
carpet, or in dancing. Boyer, Sir Astley Cooper, and others mention similar 
examples. 

Pathological Anatomy. — Most frequently the dislocation is only par- 
tial, the inner half of the patella resting upon the articular surface of the 
outer condyle; and in consequence of the peculiar obliquity of these 
surfaces, together with the action of the vasti and rectus femoris, the 
outer margin of the patella becomes tilted forward. If the dislocation is 
more complete, this margin begins to fall over backward, as in the 
accompanying drawing (Fig. 483); and in more extreme cases the patella 
lies flat upon the outer side of the condyle, with its inner margin directed 
forward. When the dislocation is partial, it is probable that neither the 
capsule nor the ligamentum patellae usually suffers much laceration ; but 
in complete dislocations the capsule at least must have given way more 
or less. 

Norris, of Philadelphia, reports a case of partial dislocation in which the com- 
plications were more serious. J. S. , set. 32, was admitted to the Pennsylvania 
Hospital, on the 27th of August, 1839, in consequence of injuries received a 
short time previous by having become entangled in machinery. In addition to 

1 Chassaignac, Bull. Soc. de Chir. de Paris, Seance du 28 Janv. 1853, p. 391. 



752 



DISLOCATIONS OF THE PATELLA. 



several fractures in other limbs, he was found to have a subluxation of his left 
patella outward, its outer edge being much raised, and resting on the side of the 
external condyle of the femur, while its inner edge was depressed, and firmly- 
fixed in the hollow between the condyles. The internal lateral ligament of the 
knee was ruptured, allowing the head of the tibia to be moved considerably out- 
ward. A depression existed, also, between the tubercle of the tibia and the 



Fig. 483. 



Fig. 484. 





Dislocation of the patella outward. 



External appearances in outward dislocation. 



lower end of the patella, at the middle and inner side of the knee, evidently pro- 
duced by a rupture of the ligamentum patellae in nearly its whole extent. There 
was almost no swelling, and the limb was moderately flexed. By firm pressure 
the patella could be restored to position, but as soon as the hand was removed it 
returned to its original position. At the end of two months " a good degree of 
motion existed at the knee-joint, which was in no way inflamed or painful." 1 

M. Berger has gathered six examples of ancient complete dislocations outward, 
which have been examined anatomically, namely, two by Verneuil, two by 
Tainturier, and two by Philipeaux and Fuhrer. In each of these examples the 
patella rested upon the tuberosity of the external condyle, which in two cases, of 
Philipeaux and Tainturier, had become articular, flattened, and covered by 
newly formed cartilage of considerable thickness. The patella was thickened 
and globular in the case of Verneuil. It was also rather triangular than rounded 
in the case described by Tainturier. In Philipeaux's case it was atrophied to 
about the size of a two-franc piece. The diarthrodial cartilages in one of Ver- 
neuil's cases, upon both the femur and tibia, were entire : the external condyle 
was flattened, and in consequence of the pressure the intercondyloidean space 
was diminished posteriorly. Tainturier has noted a sort of tortion of the femur 
from without inward. In two or three of these cases there was observed a lacer- 
ation of the internal ligaments of the patella, and in one of Verneuil's cases the 
tendon of the vastus internus was torn also. 2 

Vesale, 3 Textor pere, 4 Vering, 5 Monteggia, 6 Dupuytren, 7 and Hamoir, 8 have 



1 ISTorris. Amer. Journ. Med. Sci., Feb. 1840, vol. xxv. p. 276. 

2 Berger, Art. Rotule, Die. Encyc. Sci. Med., ser. 3, t.'.v. p. 343 (Poinsot). 

3 Berger, loc. cit., p. 341. * Ibid. 5 Ibid. 
6 Malgaigne, op. cit., p. 906. 7 Ibid. 8 Ibid. 



DISLOCATIONS OF THE PATELLA OUTWARD. 758 

also observed cases in which the displacement interfered but little with the use- 
fulness of the limb. 

In a case seen, however, by Berard, the patient had a dislocation of several 
years' standing, and there was partial ankylosis of the knee in a position of semi- 
flexion. Stromeyer and Hopfe have each met with a similar example. 

Fowler 1 met with a case in a girl, set. 21, which dated from her fifth year, and 
who was so much maimed that Dr. Fowler thought it proper, first, to divide sub- 
cutaneously the " patellar tendon," but without any satisfactory result. Eighteen 
days later he excised the patella, From the report of this case it must be inferred 
that her condition was not improved by this operation. 

Symptoms. — The limb is slightly bent, but immovable ; the breadth of 
the knee is considerably increased ; the inner condyle projects unnaturally, 
and the patella is distinctly felt upon the outer side. If the dislocation 
is partial, the outer margin of the patella forms an irregular sharp ridge 
in front of the external condyle. If it is complete, the inner margin 
presents itself in front of the external condyle, and the outer margin 
looks backward. Usually the patient suffers great pain as long as the 
dislocation remains unreduced. 

Watson, of New York, saw a case of complete dislocation of the patella out- 
ward in a fat young lady with lax fibre, and occasioned by dancing. He says 
the knee was slightly but firmly flexed. It was reduced by very slight pressure 
with the fingers, and although some inflammation with effusion into the joint 
ensued, the use of the limb was completely restored in a week or ten days. 2 

Prognosis. — Reduction is in general easily accomplished, but a redis- 
location is very prone to occur. In a few examples reported of a per- 
manent dislocation, the patients have eventually recovered the use of the 
limb in a great measure. Boyer saw four cases of this kind, in three of 
which it existed in the left leg, and had remained from infancy. The 
patellae were easily replaced, but unless confined they soon became dis- 
placed again ; not one of them found it necessary to apply for surgical 
aid, as "they suffered no great inconvenience from the dislocation, and 
it exempted them from military service/' After reduction very little or 
no inflammation usually follows. 

Mr. Key has, however, narrated a case of death from suppuration in the knee- 
joint, following upon the reduction of an Inward subluxation. The dislocation 
was produced by a fall while carrying a pail, and was reduced by very gentle 
pressure; but the patient, a girl a?t. 20, although apparently in good health, was 
believed to be somewhat strumous. 3 

Treatment. — In order to relax completely the quadriceps extensor, by 
whose action chiefly the patella is held in its unnatural position, the body 
should be bent forward, while at the same moment the leg is extended 
upon the thigh and the thigh flexed upon the body. The surgeon will 
accomplish these indications in 'the most simple manner by placing the 
patient in a chair and then lifting the foot upon his own shoulder, as he 
kneels or sits before him. Sometimes the patella will resume its position 
at once when this manoeuvre is adopted ; but if it does not, slight lateral 

1 Fowler, The Lancet, May 6, 1871. 

2 Watson, New York Journ. Med., vol. i. p. 306. 

3 Guy's Hospital Eeports, vol. i. p. 260. 

48 



754 DISLOCATIONS OF THE PATELLA. 

pressure, made with the fingers, will generally be found sufficient to 
accomplish the reduction. 

A man, set. 27, was sitting on a box, and in jumping off tripped himself with 
his right leg, causing a partial dislocation of the patella of the left leg outward. 
Half an hour after the receipt of the injury I found him sitting with the knee 
bent, and in great pain. The patella lay upon the outer half of the articular 
surface, with its outer margin a little tilted upward. Lifting the leg and thigh 
to a right angle with the body, and making very slight pressure upon the outer 
margin of the patella, it immediately resumed its place. Very little inflamma- 
tion ensued. 

In some instances, where other means have failed, the reduction has 
been eifected by violent flexion and extension of the knee, aided by 
lateral pressure. 

I have already mentioned, when speaking of dislocation into the foramen thy- 
roideum, the case of N. Smith, in whose person I found at the same moment a 
dislocation of the thigh, a subluxation outward of the tibia, and a complete out- 
ward dislocation of the corresponding patella. This was occasioned by a fall 
from a height upon the inside of the knee. I reduced the tibia first, and then 
easily replaced the patella by lifting the leg and pushing with my fingers against 
its outer margin. 

In many cases the patients themselves have reduced the dislocation 
immediately, and the surgeon is only consulted in relation to the after- 
treatment. 

Liston says that this is so constantly the fact, or else such dislocations are 
really so rare, that it has never happened to him to have an opportunity of 
reducing any form of dislocation of the patella. 

A young gentleman, set. 25, called upon me in consequence of having discov- 
ered a floating cartilage in his knee-joint. His account of the matter was that 
on the 1st of February, 1858, he was kicked by a cow upon the outside of the 
right leg, about six inches below the knee, and that he immediately found the 
patella dislocated outward. After several efforts, he finally succeeded in reducing 
it himself. His knee soon became greatly swollen, so that for five weeks he was 
unable to walk, and he has been more or less lame to this time. Six months after 
the accident he discovered a floating cartilage on the inside of the patella, about 
one inch in diameter, which occasionally slips between the joint surfaces, and 
suddenly trips him up. 

In 1870 M. Duplay 1 found in the Hospital Beaujon, a man, set. 25, with an 
incomplete external dislocation of the patella, of recent occurrence, and which 
he was unable to reduce by any of the ordinary methods. Duplay then, the 
patient being chloroformed, introduced through the integument, and fastened 
firmly into the projecting portion of the patella a strong hook, by pulling upon 
which the bone was restored to position. 

In a case of recent dislocation which proved to be irreducible, Moreau 2 opened 
the capsule and passed an elevator between the patella and the femur, but he 
was then unable to reduce the dislocation. " The consecutive accidents were 
formidable." 

It seems proper to repeat here what has been said before, that the 
facts of modern surgery do not justify the assumption occasionally made 
by my contemporaries, that the knee-joint can be invaded with impunity, 

1 Duplay, Bull. Soc. de Chirurg. de Paris, 1870. 

2 Moreau, Poirtsot, op. cit., p. 1121. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 755 

and that "formidable accidents" are not likely to ensue despite antisep- 
tics, drainage, and the other appliances of modern surgery. 

[The necessity of operative procedures for the restoration of a dislocated 
patella, must be left to the discretion of the surgeon in each individual case. 
While the warning here given, that the knee-joint cannot be invaded with im- 
punity, is useful as a general statement, it should not prevent any operation — 
even the free opening of the joint antiseptically — necessary to the complete 
recovery of the functions of the articulation. No formidable accidents are likely 
to follow such an operation properly protected by antiseptics, drainage, and the 
other appliances of modern surgery.] 



Fig. 485. 



§ 2. Dislocations of the Patella Inward. 

The existence of a complete inward dislocation has been denied by 
Nelaton, Streubel, and questioned by Malgaigne. One example of incom- 
plete dislocation has been described anatomically by 
Key, and which has been already referred to as hav- 
ing terminated in death from suppurative arthritis. 
In this case there were found laceration of the outer 
portion of the capsule, and a partial rupture of the 
tendon of the vastus externus. 

Causes. — They are occasioned generally by direct 
blows received upon the upper margin of the patella. 
The symptoms and treatment will be the same as in 
dislocations outward, except so far as these must neces- 
sarily vary from the opposite position of the patella. 

§ 3. Dislocations of the Patella upon its Axis. 

(a) Vertical. 



Syn. — " Semi-rotation 
gaigne. 



Miller. " Luxation Verticale ; " Mal- 




These accidents, of which I have found recorded 



Dislocation of the 
patella inward. 



about twenty-four examples — and one additional case 
has been seen by myself — seem to be the result of the same causes which 
produce lateral dislocations ; and, indeed, they may be regarded as only 
exaggerated forms of incomplete lateral dislocations. In these latter acci- 
dents, as we have already noticed, the external or the internal margin of 
the patella, according as the subluxation is to the outer or inner side, 
is thrown more or less obliquely forward ; a position into which it is 
carried partly by the peculiar form of the articulating surfaces, and 
partly by the action of the vasti and rectus femoris muscles. If now 
these muscles were to contract suddenly and violently, and the return of 
the patella to its normal position were prevented by the lodgement of one 
of its margins in the inter-condyloidean fossa, the other or free maro-in 
would be compelled to rise until it became perpendicular to the limb, or 
it might perhaps even become completely reversed. 

Symptoms. — The signs of the accident are such as to render an error 
in the diagnosis almost impossible. The limb is generally found forcibly 



756 DISLOCATIONS OF THE PATELLA. 

extended, occasionally it is in a position of moderate flexion, but the pro- 
jection of the sharp border of the patella directly forward under the skin 
is itself sufficient to determine the true nature of the injury. 

Treatment. — Reduction may be effected by the same manoeuvres which 
I have recommended in lateral dislocations ; but if these measures do not 
succeed, we may direct the patient to make a violent effort himself to flex 
and extend the limb, or the surgeon may force the limb into flexion and 
extension alternately, or he may rotate the tibia upon the femur, and 
then flex. Finally, he ought to make use of lateral pressure also, upon 
both margins of the upright patella, but in opposite directions. 

In all cases it would be advisable to put the patient under the influ- 
ence of an anaesthetic before attempting reduction. 

In a case reported by Dr. H. Hunt, of Beloit, the reduction occurred sponta- 
neously as soon as the patient was chloroformed, although it had resisted all the 
efforts previously made. 1 

Watson, of New York, has related the following example of rotation- of the 
patella upon its inner margin (" Luxation Verticale Externe," Malg.) : H. B., 
aged about 35 years, of rather slender frame, while riding on horseback in a 
crowd, received a blow upon his knee from a horse ridden by another person. 
When seen by Dr. Watson, soon after the accident, the leg was perfectly straight, 
but could be flexed to about an angle of 140° without causing pain. " The patella 
appeared to be slightly drawn up, and it was twisted upon its axis, presenting 
its outer edge, in a prominent hard line, in front of the knee ; its inner edge 
was resting either in the groove between the condyles of the femur, upon which 
its posterior face should naturally play, or in the small depression on the ante- 
rior face of the femur, immediately above this groove. The anterior surface of 
the patella was turned inward, its posterior surface outward, and it rested nearly 
at right angles with its natural position. Its upper and lower attachments were 
both preserved, and could be distinctly felt ; and a sort of band appeared to 
pass from its under, or, as it now lay, its outer face inward to the deeper portion 
of the knee-joint. This band, as I conceived, was caused either by the tension 
of the capsular ligament, or by the rupture of its edge, as it passes from the outer 
side of the patella. The position of the bone was so well marked that no one 
at all acquainted with the anatomy of the part could mistake the nature of the 
accident. With the leg extended, and the anterior muscles of the thigh forced 
downward as much as possible, pressure was made upon the patella, with the 
expectation of forcing down its prominent edge. The effort was followed only 
by an increase of pain, the bone remaining permanently fixed. Another attempt 
was made to cant its posterior edge inward, and to bring its anterior edge out- 
ward, without pressing against the condyles of the femur, by forcing the head of 
a key against the posterior, now the outer, face of the patella (using this as a 
fulcrum), and pressing the prominent edge of the bone toward the outer condyle. 
This manoeuvre gave him no pain, but was as fruitless in its result as the other. 
At length the knee was forcibly bent and immediately straightened again ; and 
then, by canting the patella as before, and pushing it slightly downward and 
inward, it sprung with a sudden snap into its proper position." 2 

Dr. Joseph P. Gazzam, of Pittsburg, Pa., has met with a similar case: On the 
10th of September, 1842, a man was thrown while wrestling, and immediately 
found himself unable to rise. Dr. Gazzam saw him about an hour after the acci- 
dent, and found the patella of the right leg dislocated on its axis, and resting 
on its inner edge in the groove between the condyles of the femur. Dr. G. pro- 
ceeded to attempt reduction, but failed, after having made repeated trials by 
lifting the limb toward the body and by pressure in opposite directions. In 
consultation with Dr. Addison, it was now determined to divide the ligamentum 
patellae, which was done by introducing beneath the skin a narrow-bladed knife,. 

i H. Hunt, M.D., The Medical Record, April ], 1873. 
2 Watson, New York Journ. Med., Oct. 1839, p. 302. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 757 

and cutting close to the tubercle of the tibia. Again the attempts at reduction 
•were renewed, but without success. The patella could be moved on its edge 
more freely than before the cutting, but resisted every effort to replace it. The 
patient was now bled in the erect posture, and until the approach of syncope, 
but to no purpose. On the following morning it was determined to adopt, with 
some modification, the mode practised so successfully by Dr. Watson. "The 
thigh was strongly flexed," says Dr. Gazzam, "on the pelvis, and the heel ele- 
vated. Then the leg was flexed steadily and forcibly on the thigh, and suddenly 
straightened. At the moment of straightening the leg, I pressed very strongly 
against the lower edge of the patella from without, with the head of a door-key 
well wrapped, while Dr. Addison pressed with both thumbs against the upper 
edge of the bone toward the external condyle. On the fourth trial this manoeuvre 
succeeded, the bone springing into its place with a snap." Recovery was unin- 
terrupted, and two or three months after, the patient had the complete use of 
his limb. 1 

The following case is reported by Dr. S. F. Morris, New York : 

"Mr, B., aged 27, of slender build, while playing at ball, in endeavoring to 
strike the ball had to jump up and turn partially round, when, on resuming his 
former position, he fell, his leg refusing to bend. He appreciated the nature of 
his injury, and, with the aid of the men in the store, endeavored to 'push it 
back.' Failing in this, surgical aid was sought, but, despite three attempts at 
reduction, the patella remained displaced. He w T as then taken to his home. I 
saw him about tw r o hours after the accident. He complained of severe pain 
when any manipulation was made. The leg was perfectly straight. The patella 
was firmly wedged (its outer edge) in the inter-condyloid fossa ; its anterior sur- 
face looking outward and slightly downward, its posterior face looking inward 
and upward. The prominence of the edge of the patella, thus twisting on its 
longitudinal axis, left no doubt as to the diagnosis. No attempt w r as made at 
reduction by me until the patient was etherized, when, assisted by Dr. C. M. 
Bell, of this city, it was easily performed in the following manner : The leg was 
raised from the bed, the thigh flexed upon the pelvis. Dr. Bell then placed his 
thumb, as a fulcrum, beneath the under (posterior) surface of the patella, and 
pressed on the upper (anterior) surface ; at the same time I slightly flexed, then 
suddenly extended and rotated the leg inward. The patella immediately re- 
sumed its natural position." 2 

The following case is reported by G-. P. Davis, M.D., of Hartford, Conn. : " A 
few weeks ago I was summoned to a nurse girl, who was reported to have ' put 
her knee out of joint.' On entering the room, I found the patient lying on her . 
face, both legs extended, and the left foot pointing toward its fellow. On turn- 
ing the patient upon her back, the left patella was plainly seen in a condition of 
* vertical' displacement, i. e., turned upon its inner edge, so that its upper sur- 
face looked toward the opposite knee. It was rigidly fixed, and the limb was 
entirely helpless. I learned that while sitting upon the floor, playing with the 
baby under her charge, she suddenly reached forward, at the same time twisting 
her body partly around, in order to seize the child, who was a little out of her 
reach, and who, she feared, was about to fall. She immediately became con- 
scious that an accident had befallen her knee. The patient was etherized as she 
lay upon the floor. The whole limb was then elevated by an assistant, so as to 
relax the muscles in front of the thigh, and, by forcibly crowding down these 
muscles toward the knee with one hand, manipulating the patella at the same 
time w T ith the other, reduction was effected with the utmost ease." 3 

Through the courtesy of Dr. A. E. Robinson and of Prof. S. B. Ward, of New 
York, I saw a case of " semi-rotation " of the patella. The accident had hap- 
pened the day before, in the person of Susan N., set. 31, a muscular Scotch 
woman, while wrestling. Dr. Robinson being called, attempted reduction by 
pressure and by other means, but without success. About seventeen hours after 
the accident I found her in bed with the left leg extended upon the thigh, and 
the patella standing upon its inner margin, which rested in the inter-condyloid 

1 Gazzam, Amer. Journ. Med. Sci., vol. xxxi., April, 1S43, p. 363. 

2 Morris, The Med. Record, Mav 3 5, 1869. 

3 Davis. The Med. Record. Dec."l, 1874. 



758 DISLOCATIONS OF THE PATELLA. 

notch. The patella was not vertical, but leaned over toward the outside of the 
knee. While placing her under the influence of chloroform, she bent her leg to 
a right angle, but the patella continued to occupy its abnormal position. When 
completely under its influence, Dr. Ward extended and flexed the leg with no 
result. He then tilted the patella down until it lay flat upon the outer condyle 
(this was the position it took also when, being partially chloroformed, she flexed 
the leg) ; and after a second attempt, with moderate pressure against the outer 
margin of the patella, it suddenly resumed its position. None of the tendinous 
or muscular attachments were ruptured. 

Dr. J. M. Boyd, of Thorntown, Indiana, reports a case of vertical dislocation, 
the patella resting upon its internal margin, in a negro 38 years old, and which 
was caused by muscular " spasms. '' Attempts were immediately made by a sur- 
geon to reduce it, but without success. Subsequently Dr. Boyd tried also and 
failed ; but at the end of two weeks the muscular spasms returned, and before 
Dr. Boyd could reach the house the bone had resumed its position spontane- 
ously. 1 Malgaigne has reported, also, a case in which the reduction was accom- 
plished spontaneously during an attempt made by the patient to walk. The 
same writer refers to a case reduced under the influence of chloroform. Mr. 
Flower records a similar case. 2 

In a case of the same kind, 3 the reduction was found impossible, notwith- 
standing the surgeon finally had the temerity to sever completely the tendon of 
the quadriceps extensor and the ligamentum patellae. Extensive suppuration 
followed, under which the poor fellow finally sank and died. 

Dr. Dougherty, of Newark, N. J., has reported a case in which he succeeded 
in effecting reduction by pressure made with his hand while the limb was in an 
extended position, and without anaesthesia. 4 

Dr. Bradner, ot Warwick, Orange Co., N. Y., reports a case occurring in a 
boy, set. 9 years, caused by a fall in wrestling. The limb — the right — was 
slightly flexed. He describes the reduction as follows: "To relieve the strain 
upon the patella preparatory to reduction, I seized his ankle in my right hand, 
and raised it from the bed ; then I placed my left hand over the patella and 
grasped the knee ; then by depressing the knee forcibly with one hand, and 
raising the heel with the other, I found it a very easy matter to rotate the patella 
to its normal bed." The boy recovered at once the complete use of his limb. 5 

Dr. W. R. Cluness, of Sacramento, Cal., reports a case reduced by him in the 
extended position and by lateral pressure. 6 

In a case occurring in a lady, 36 years of age, solely from muscular action, the 
reduction was easily effected by Dr. Taylor, Assistant Surgeon U. S. A., by 
bending the knee as much as possible, and then suddenly straightening it, while 
at the same moment the patella was pressed firmly over. 7 

In two cases Cuynat 8 has followed successfully the example of Moreau, 
already referred to in connection with dislocations outward, by introducing an 
elevator through an incision ; and without any of the " formidable " accidents 
which ensued in Moreau's case. 

(b) Complete Version. 

Syn. — " Renversement : " Malgaigne. 

Complete version, like partial version, presents two varieties, namely, 
version from without inward and version from within outward. 

In the earlier editions of this treatise, this dislocation is referred to as repre- 
senting the most advanced or complete form of patellar rotation ; but I have 

1 Boyd, Western Journ. Med., May, 1868, p. 275, and June, 1868, p. 341. 

2 Holmes's Svst. Surg. 3 Rust's Magazine. 
* Dougherty, 'The Med. Record, Dec. 30, 1876, p. 840. 

& Bradner, Ibid., Jan. 20, 1>77, p, 46. 

6 Cluness, Ibid., Jan. 27, 1877. 

7 Taylor, Ibid., May 26, 1877, p. 336. 

8 Cuynat, Recueil de Mem. de Med. de Pharm. et Chir. Militv, t. 16, t. 18. 



DISLOCATIONS OF THE PATELLA UPWARD. 759 

decided hereafter to speak of partial version (vertical) and complete version as 
two distinct forms. 

Malgaigne 1 refers to a case reported by J. Sue in 1752, 01 version from with- 
out inward, which was not, however, complete, and which was unaccompanied 
with a rupture of the ligaments. Later, Bruyeres is reported to have said to 
the Royal Academy of Surgeons that he had seen a complete version of the 
patella, and without rupture of the ligaments. 

Castara 2 reports a case of complete version from within outward, in a girl of 
17 years ; the tendon and ligamentum patellae were twisted into a cord. Reduc- 
tion was easily effected by seizing the patella between the thumb and index 
finger, and by rotation from behind forward, and from without inward made 
slowly and gently. 

Berger cites a similar case as having been published by Gaulke 3 in a girl of 17 
years, who had fallen from a horse. Gaulke, who did not see the case until after 
ten days, was at first unable to effect reduction, even when the patient was under 
the influence of chloroform. On the followiug day Gaulke procured a carpenter's 
wooden vice, and enclosing in its grasp the internal condyle and the outer 
margin of the patella, he succeeded, after several ineffectual efforts, in restoring 
it to position ; but not without some laceration of the integuments. Recovery 
took place speedily, and without any inflammatory accidents. 

§ 4. Dislocations of the Patella Upward. 

Occasionally the ligamentum patellae has been found so much elongated 
and relaxed, as to permit the patella to glide upward upon the front of 
the femur. Heister and Ravaton have each seen an example in which a 
displacement from this cause existed to the extent of three inches. It is 
much more common, however, to meet with this dislocation as a result of 
a rupture of the ligamentum patellae. 

On the 18th of Dec. 1850, D. M., set. 50, was admitted to the surgical wards of 
the Buffalo Hospital of the Sisters of Charity. While at work on the same day, 
he had slipped and fallen, with his knee forcibly flexed under his body. I found 
the ligament of the patella torn asunder, and the patella drawn up two or three 
inches upon the front of the thigh. We applied at once the dressings used by 
me for a broken patella, and were able to bring the bone down completely to its 
place. Three weeks from the time of the receipt of the injury the dressings 
were removed, and the patella was found to be nearly but not quite in its original 
place. From this time we commenced to move the joint; in about ten days 
more he left the hospital, and I lost sight of him, so that I am unable to speak 
more definitely of the result. 

Mrs. Fanny N., set. 45, fell upon her right knee, causing a lacerated wound 
and a rupture of the ligamentum patellae. Four years later, Oct. 28, 1880, I 
found the patella one and a half inches above its natural position. She was 
able to walk up and down stairs without difficulty, and while sitting she could 
lift the leg and straighten it upon the thigh perfectly. 

The following case is unique : Miss M. E. B. was thrown in alighting 
from a stage, and, on consulting a druggist, was told that she had ruptured the 
ligamentum patellae. Some time later, Oct. 20, 1880, she consulted me, when I 
found the lower edge of the left patella tilted forward, with a manifest depression 
below the patella caused by the absence of the anterior, or most superficial 
fasciculus of the ligament. The posterior fasciculus, attached to the posterior 
margin of the patella, could be distinctly felt, and seemed to be normal in length 
and breadth. In walking the knee is apt to give way suddenly, as happens 
when there is a floating cartilage in the joint. I directed her to wear an elastic 
knee-cap ; but she omitted to do this except occasionally, and when she again 

1 Sue, Malgaigne, op. cit., vol. ii. p. 918. 

2 Castara, Malgaigne, op. cit., p. 921. 3 Gaulke, Deutsch. Klin., vol. ii. 1863. 



760 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

consulted me, about one year later, there was no appreciable change in the con- 
dition of the limb. 

In February, 1869, Dr. G. H. Smith consulted me in relation to a gentleman 
who had ruptured the ligament of the patella in both legs a little more than a 
year before by catching his heel in descending from a carriage, the ligaments 
giving way in the powerful muscular effort which he made to prevent himself 
from falling. Treated upon a single inclined plane in the same manner that I 
have recommended for a fractured patella, at the end of five weeks the patellae 
were in place and the ligaments reunited. After walking about one month 
upon crutches he caught the heel of his right foot again, and again ruptured the 
ligament of the patella in the same leg. A similar plan of treatment failed to 
accomplish anything, and when he consulted me the patella was displaced three 
inches upward, He could raise the leg slowly to a position of extension while 
sitting, and was able to walk four or five miles a day. 

Gibson has recorded a similar case, in which both patellae were dislocated up- 
ward by a rupture of the ligaments, occasioned by the exercise of leaping. He 
recovered the use of his limbs almost completely. 1 

[If the ruptured ligamentum patellae fail of union, and the limb is thereby 
crippled, a union may be secured by free incision of the structures and sutures 
through the lower extremity of the patella, and the fibrous tissues remaining at 
the lower attachments of the ligament. A similar operation may be performed 
for rupture of the quadriceps tendon. ] 



(For examples of rupture of the quadriceps femoris, which some writers have 
incorrectly named Dislocations of the Patella Downward, see Velpeau's Surgery, 
1st Amer. ed., vol. i. p. 422 ; New York Med. Times, April 6, 1861, p. 226, and 
two cases reported by myself in the same volume of the Med. Times ; Demar- 
quay, Mem. Rup. Tend, du Triceps, Gaz. Med., Paris, 1842 ; Renouard, Arch. 
Gen. de Med., ser. 4, t. xv. p. 101 ; Binet, Rup. Tend. Triceps et du Lig. Rotu- 
lien, Arch. Gen. de Med., ser. 5, t. ii. p. 687, 1858 ; Adams, Case of Rupture of 
the Tendons of both Recti Fern., Lancet, 1861, vol. ii. p< 226 ; Lorinser, Wiener 
med. Woch., 1869, Bd. xix. S. 27 ; Berger, Art. Rotule, Die. Enc. Sci. Med., ser. 
3, t. v. p. 330.) 



CHAPTER XIX. 

DISLOCATIONS OF THE HEAD OF THE TIBIA (FEM0R0-TI3IAL). 

Syn. — "Tibia upon the femur;" "dislocations of the leg " 

In consequence of the great size and irregularity of the articular 
surfaces between the tibia and femur, together with the remarkable num- 
ber and strength of the ligaments which bind the two bones together, 
dislocations at this joint are exceedingly rare. They are known to take 
place, however, in four principal directions, namely, backward, forward, 
inward, and outward. A dislocation may also occur in either- of the 
diagonals between these points, that is, antero-laterally or postero-laterally, 
or the tibia may be dislocated by rotation. Dislocations of the head of 
the tibia may be either complete or incomplete. 

1 Gibson, Surgery, vol. i. p. 395, 6th ed. 



DISLOCATIONS OF HEAD OF TIBIA BACKWARD, 



761 



Velpeau found upon record thirteen examples of complete dislocations forward 
and eight backward, but not one of a complete lateral dislocation. Velpeau 
thought, also, that the antero-posterior dislocations were always complete, but 
Malgaigne has shown that this opinion is erroneous. 



§ 1. Dislocations of the Head of the Tibia Backward. 



Fig. 486, 




Complete dislocation, ot 
head of tibia backward. 



The head of the tibia is felt in the popliteal space, and, if the disloca- 
tion is complete, the pressure upon the popliteal nerve becomes excessively 
painful. A marked depression exists in front, 
immediately below the patella, and especially 
upon the sides of 1 the ligamentum patellae ; the 
condyles of the femur project strongly in front ; 
the leg may be not at all (incomplete) or only 
slightly shortened, or the shortening may amount 
to one inch or more ; and usually it is in a position 
of extreme extension, or thrown forward from the 
line of the axis of the femur ; but its position has 
been found to vary greatly in different cases, the 
limb being sometimes very much flexed, and in 
others very slightly flexed or perfectly straight. 

Pathological Anatomy. — The posterior ligament 
of the joint is torn ; the muscles of the ham are 
stretched: the popliteal nerves and vessels com- 
pressed ; and the head of the tibia either rests 
partly upon the posterior half of the lower articu- 
lating surface of the femur (incomplete), or it passes 
up and rests only against its posterior articulating 
surface, which in this direction extends an inch or 
more upward. If the dislocation is complete, the crucial ligaments are 
also torn, and all the parts about the joint suffer extensive injury from 
stretching, laceration, or compression. 

Prognosis. — If the reduction is promptly effected, the limb kept per- 
fectly quiet a sufficient length of time, and in other respects properly 
managed, not much inflammation need generally be anticipated, and the 
limb may suffer in the end very little, if any, maiming. 

Malgaigne has seen three examples of incomplete backward dislocations 
which were not reduced, and neither of the persons was very greatly maimed in 
consequence. One walked with crutches after three or four days, and with a 
cane after about five weeks. Another did not leave his bed under one month, 
and it was nearly one year before he could lay aside his crutches ; but both of 
them were finally able to walk at least twelve leagues per day. Malgaigne 
informs us, however, that in a similar case seen by Lassus the patient was con- 
fined to his bed two years, although he finally recovered a tolerable use of his 
limb. 

Treatment. — It will be proper, at first, to attempt the reduction by 
simple manipulation, as this is often found to succeed when the disloca- 
tion is recent and incomplete, and especially when the system is greatly 
depressed by the shock of the injury. If the dislocation is complete, 
however, we can hardly anticipate success "without the application of 



762 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

some extending force. In the employment of manipulation we ought to 
be governed at first by the same rule which we have found so generally 
applicable in dislocations of the femur, namely, to carry the limb in those 
directions in which it will move easily, or without the application of much 
force. If this fails, we may at once resort to forced flexion alternating 
with extension ; rotating or rocking the limb also occasionally from one 
side to the other, while at the same moment strong pressure is made upon 
the projecting bones at the knee-joint in opposite directions, or in the 
direction of the articulation. Finally, it may be necessary to resort to 
extension, made by means of a lacque, or by the hands of strong assist- 
ants, above the ankle, always at first in the direction of the axis of the 
tibia ; the counter-extending band being applied to the perineum if the 
leg is straight, but to the lower and back part of the thigh if the leg is 
flexed. A very convenient mode of making extension, where we wish 
to apply more than usual force, is to lay the whole limb over a firm 
double inclined plane, or fracture-splint, securing the thigh to the thigh- 
piece with a roller, and making the extension with the screw attached to 
the foot-board. This method, however, while it enables us to use great 
force in the extension, prevents the surgeon from employing, at the same 
time, those flexions, extensions, and other manipulations, upon which 
success so often depends. 

Dr. James Carmichael has reported a case in which reduction was effected 
easily by flexion, when traction failed. 1 

Mr. Eose 2 has related a characteristic example of this accident, except that 
the patella had also suffered a lateral displacement, presenting the usual favor- 
able termination. A woman was standing upon a low ladder when a carriage, 
driven furiously, came in contact with it, and precipitated her to the ground. 
Mr. Rose, who saw her almost immediately, found the tibia completely dislo- 
cated at the knee, the head being driven behind the condyles of the femur into 
the ham, with the patella thrown to the outside of the external condyle, and 
the leg in a state of fixed extension. Immediately, and without difficulty, the 
bones were restored by applying one hand to the patella, the other to the back 
of the upper portion of the tibia, and simultaneously pulling and pushing those 
bones toward their natural positions. The patient was then removed to a bed, 
and by the diligent use of antiphlogistic remedies inflammation was kept in 
check, and the case reached a favorable termination without one untoward 
symptom. After the lapse of only a few weeks she had completely recovered 
the use of the knee-joint. 3 

Dr. Walsham communicated a case to Sir Astley Cooper in which the disloca- 
tion was not only complete, but the tendon of the quadriceps extensor was rup- 
tured. The leg was bent forward. The reduction was accomplished very easily 
by extension, made with the hands by four men, in the line of the axis of the 
limb. In about one month this man began to walk with crutches, but he was 
not perfectly recovered until after five months, at which time the crutches were 
finally laid aside. 4 

§ 2. Dislocations of the Head of the Tibia Forward. 

The signs of this accident are the reverse of those which belong to 
dislocations backward. The patella, tibia, and fibula are prominent in 

1 New York Med. Gazette, Aug. 22, 1868, from the Lancet. 
2 , Provincial Med. Journal, June 11, 1842. 

3 Rose. Amer. Journ. Med. Sci., vol. xxxi. p. 216. 

4 Walsham, Sir A. Cooper on Disloc, etc., 2d London ed., p. 188. 



DISLOCATIONS OF HEAD OF TIBIA FORWARD. 



763 



front, while the condyles of the femur may be felt behind, pressing 
strongly upon the muscles, nerves, and bloodvessels which occupy the 
popliteal space. In case the dislocation is complete, a shortening may 
exist to the extent of one or even three inches. 



Fig. 487. 



Dr. O'Beirne, of Dublin, has mentioned a case to Mr. B. Cooper in which the 
shortening was three inches and a half, and Mr. Mayo has seen one example in 
which the dislocated limb was "fully four inches" shorter than the other. 1 

In consequence of the pressure upon the popliteal artery, the pulsa- 
tions in the branches below are frequently interrupted, and in one instance 
this pressure was sufficient to produce finally a dry gangrene. 

Dr. Gorde 2 relates a case occurring in a woman nearly sixty years old. This 
woman was returning home at night with a heavy burden, and in a state of 
intoxication, when she stepped into a ditch as 
deep as up to the middle of her thighs. The 
body was thrown forward by the fall, while the 
feet struck at the bottom of the ditch, the whole 
force of the impulse being sustained by the 
thighs. The lower end of the femur was found 
driven downward and backward, and lodged 
under the muscles of the calf of the leg; the 
limb being shortened three inches. Reduction 
was promptly effected, and without inflicting any 
pain of which the patient complained. In six 
weeks the patient was cured. 3 

Mr. Toogood has reported an example of com- 
plete dislocation in this direction, in which the 
appearance was so dreadful, that Mr. Toogood at 
first despaired of being able to reduce it ; but by 
directing two men to make counter-extension 
while he made extension, the reduction was im- 
mediately effected. At the end of one month 
the patient was able to leave his bed ; and six- 
teen years after, Dr. Toogood saw him walking 
" with very little lameness."* Parker, of Liver- 
pool, has reported another example, which was 
occasioned by the fall of a heavy spar upon a 
man's back, and the consequent violent bending 
of the knee under his body. In this case the limb was slightly flexed, and the 
patella was loose and floating. The reduction was effected without much diffi- 
culty by extension and counter-extension made by two men, while the operator, 
placing his knee in the ham of the patient, attempted to bring the leg to a 
right angle with the thigh. 5 

B. Cooper, Malgaigne, Little, 6 and others, have recorded examples of this acci- 
dent. 

March 9, 1865, Hiram Wescott, of Sandy Cove, Nova Scotia, set. 45, was 
caught by his sled, drawn by horses, in such a way that a beam pressed against 
the front and lower end of the femur while the heel was caught and arrested by 
a stump. ^ The foot was thrown forward and the upper end of the tibja com- 
pletely dislocated in the same direction, It was at once reduced by a person 
who was present, but on attempting to use the leg in walking it was redislo- 
cated immediately. Mr. J. H. Harris, medical student, found the limb soon 
after completely dislocated, with the leg thrown forward in the position of dorsal 

1 B. Cooper's ed. of Sir Astley Cooper on Disloc, etc., pp. 214, 215. 

2 Bulletin de Tkerapeutique." 

3 Gorde, Amer. Journ. Med. Sci., vol. xvi. p. 225, May, 1835. 

* Toogood, Amer. Journ. Med. Sci., vol. xxxi. p. 465." 5 E. Parker. Ibid. 

6 Little, Xew York Med. Times, Aug-. 17, 1861. 




Subluxation of tbe head of the 
tibia forward. 



764 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

flexion about 40°. The tendons of the hamstring muscles were not ruptured, 
but had slid forward past the condyles of the femur. There was no external 
wound. Reduction was easily accomplished by simple extension. Pasteboard 
splints were then applied. On the third day the knee was considerably swollen, 
and some ecchymosis existed about the popliteal region. On the fifth day these 
symptoms had much increased. Mr. Harris then applied extension to the foot, 
with the aid of adhesive plaster, pulley and weights, and by elevating the foot 
of the bed. The amount of exteusion employed was 9 lbs. 'This gave imme- 
diate relief to the pain, and was continued until the inflammation subsided. 
His recovery was steady, and in four months he walked with crutches or a cane. 

In 1864 a similar dislocation was presented at the Brooklyn City Hospital, in 
which reduction having been practised, the patient died. 1 

Dr. White, of Buffalo, invited me to see with him a lad, set. 10, whose tibia 
had been partially dislocated forward eight weeks before, by a boy having hit 
the top of his knee with his head, while they were at play. His father, himself 
a physician, residing near town, reduced the limb very easily, by extension made 
with his own hands, and by pressing upon the projecting bones. Violent in- 
flammation ensued, but at the time when I saw him, the knee was free from 
soreness or swelling, and the motions of the joint were nearly restored. 

Dr. Downes, of Mclndoe's Falls, Vt., gives the following account of a case in 
his practice. October, 1861, Mrs. H., a robust young married woman, aged about 
20 years, was driving a young horse and holding her infant in her arms, when 
the horse ran and she was thrown out. One of her legs being caught in the 
wheel, she was carried over three or four times in its revolutions before she 
became disengaged, holding meanwhile upon her infant with such firmness that 
it suffered no harm. A few hours later Dr. Downes and Dr. Burton found a com- 
plete dislocation of the tibia and fibula forward, and the lower end of the femur 
could be felt under the muscles of the calf of the leg. The limb was shortened 
four inches and a half. The patella lay loosely in front of the femur, with its 
lower margin tilted forward. The patient was laid upon a bed, and a perineal 
band made fast to one of the posts, while a lacque was placed upon the foot and 
attached to a rope folded upon itself and forming a pulley or " Spanish wind- 
lass," such as is described at page 694. In this way the reduction was speedily 
and easily accomplished. Hot fomentations were subsequently applied for 
several days, the limb being kept perfectly at rest. In about three months she 
was able to do her own housework, and in a short time after all traces of her 
accident had disappeared. 

The following account of a case was sent me by Dr. Alonzo Pettit, of Eliza- 
bethport, N. J. : J. McG., laborer, set. 26, was sitting upon the platform of a 
freight car, with his feet upon the platform of the next car, his legs extended. 
The train slacking up at a station, before he had time to bend his knees, the 
cars came together and pushed the head of the left tibia upward upon the femur. 

He saw him about half an hour after the accident, and found a complete dis- 
location of the head of the tibia, with the patella forward upon the femur. The 
leg was slightly flexed, and shortened two and a half inches. He succeeded in 
reducing it easily without assistance, or the use of ansesthetics, by grasping the 
leg with the left hand, the right being in the popliteal space, making moderate 
extension and flexion, and pressing upon the condyles of the femur. 

§ 3. Dislocations of the Head of the Tibia Outward. 

Occasionally, owing to a violent wrench of the knee-joint, the lateral 
ligaments upon one side or the other are ruptured, and consequently the 
joint surfaces separate somewhat from each other ; or when the limb is 
moved, the head of the tibia may slide a little forward or backward, or 
to either side. These are not properly examples of subluxation ; nor 
should we consider as belonging to this class the accident originally de- 

1 Yale, New York Journ. Med., vol. ii. p. 124, Nov. 1865. 



DISLOCATIONS OF THE HEAD OF THE TIBIA INWARD. 765 



scribed by Mr. Hey as an " internal derangement of the knee-joint," but 
which also by some writers has been termed " a subluxation of the knee." 
Of this latter accident I will take occasion hereafter to speak a little more 
particularly. In subluxation, properly so called, if the direction of the 
dislocation is outward, the outer condyle of the femur rests upon the inner 
articulating surface of the tibia, and if the direction of the dislocation is 
inward, the inner condyle of the femur rests upon the outer articulating 
surface of the tibia. The signs which characterize this accident are such 
as cannot easily be mistaken. The limb is not shortened, nor is there 
anything especially diagnostic in its position, since it has been found to 
be sometimes flexed, and at other times straight ; but the strong lateral 
projections made by the inner condyle of the femur on the one hand, and 
by the heads of the tibia and fibula on the other, cannot fail to inform us 
as to the true nature of the accident. The treatment will not differ 
essentially from that which has already been recom- 
mended in dislocation of the tibia backward or for- FlG - 488 - 
ward. If any other expedients can prove useful, 
they must be left to the judgment of the surgeon 
whenever the exigencies of the case shall demand 
them, i 

N. S., in consequence of a fall from a window, had a 
dislocation of the right femur, tibia, and patella. The 
tibia was subluxated outward, and the leg was partially 
flexed upon the thigh, with the toes everted. By moder- 
ate extension, made with my own hands, united with 
alternate flexion and extension, the bone was easily and 
promptly restored to its place. Very little swelling fol- 
lowed the accident, and his recovery was rapid and com- 
plete. 

A man was received into the North London Hospital, 
with a partial dislocation of the tibia outward, and although 
the knee was much swollen, the nature of the injury was 
easily determined. The knee was immovable, and the 
toes turned outward. Mr. Hallam, the house surgeon, 
reduced it by extension and counter-extension made with 
his own hands. 1 

Mr. Pitt records a similar case in a young lady, pro- 
duced by a fall down a flight of stairs. It was reduced 

easily by extension and counter-extension. Inflammation followed, but it was 
finally controlled, and she regained the use of her limbs. 2 

In one case of subluxation, mentioned by Sir Astley Cooper, and in a second 
recorded by Bransby Cooper, the recovery of the functions of the joint did not 
seem to have been so rapid ; the joint remaining unstable and tender for a long 
time afterward. 3 




Subluxation of the 
head of the tibia out- 
ward. 



4. Dislocations of the Head of the Tibia Inward. 



There is nothing peculiar in either the signs, conditions, or treatment 
of this accident, as distinguished from a dislocation outward, to demand 
a special consideration. 

1 Hallam, Amer. Journ. Med. Sci., vol. xix. p. 251. 

2 Pitt, Ibid., vol. xxxi. p. 465. 

3 B. Cooper's ed. of Sir Astley, op. eit., pp. 111-13. 



766 



DISLOCATIONS OF THE HEAD OF THE TIBIA 



Fig. 489. 



Sir Astley Cooper has mentioned two cases of subluxation inward, and Mr. B. 

Cooper has added to these a third. Sir Astley remarks that in the first accident, 
the only one indeed which he had himself ever seen, he 
was struck with three circumstances : first, the great de- 
formity of the knee from the projection of the tibia; 
second the ease with which the bone was reduced by direct 
extension; and third, by the little inflammation which 
followed. The second case of which Sir Astley speaks 
was communicated to him by a Mr. Richards. In this 
case the fibula was also broken, and the reduction was ac- 
complished only after extension had been made by several 
persons for half an hour. The limb became excessively 
swollen, and remained so for many weeks. Eighteen 
months after the accident the knee continued somewhat 
stiff, and there was an unnatural lateral motion in the 
joint, from the injury which the ligaments had sustained. 
The patient referred to by Bransby Cooper had met with 
the accident by a fall upon the foot, with his leg bent 
under him ; and a fellow-workman had reduced the bone 
by extension and pressure. Mr. Cooper thinks that not 
only the internal lateral ligament was torn, but also some 
fibres of the vastus externus and the crucial ligaments. 
Violent inflammation ensued, which did not permit him 
to leave the hospital until after about two weeks. Fer- 
gusson has seen two examples of unreduced subluxation 
inward, in both of which the patients had regained useful 
limbs. 1 

Malgaigne mentions that Boyer, Costallat, and Key had 
each seen one similar example ; and he also enumerates 

two additional cases of complete dislocation attended with a protrusion of the 

bone through an external wound ; in both of which the reduction was easily 

effected and the patients recovered. 2 




Subluxation of the 
head of the tibia in- 
ward. 






§ 5. Dislocations of the Head of the Tibia Backward and Outward. 

In June, 1853, Henry J., of Dansville, N. Y., set. 24, was thrown by an enraged 
bull, and his left leg, being caught under the knee by the horns, was twisted 
violently. Drs. Pryor, of Dansville, and Batton, of Burns, were called, and 
found the left knee "completely dislocated; the tibia being displaced backward 
beyond the condyles of the femur, and also a little outward. The foot and leg 
were inclined outward. With the assistance of four men, extension and counter- 
extension were made in the line of the axis of the limb, and the reduction was 
easily accomplished. Pasteboard splints, bandages, etc., were applied to main- 
tain the bones in place ; but the swelling came on rapidly, and in the evening 
these dressings were removed. The limb was now laid over a double inclined 
plane carefully padded, in order to press the upper end of the tibia forward, as 
it manifested a constant inclination to become displaced backward. This appa- 
ratus was employed six weeks, with the exception of two or three days, during 
which the limb was laid upon pillows, but as the pillows did not sufficiently 
support the back of the tibia, the double inclined plane was resumed. After the 
removal of the plane, during seven weeks longer, an angular splint was kept 
closely applied to the back of the limb. Seven months after the accident, on 
the 23d of January, 1854, Dr. Robinson, of Hornellsville, brought the gentleman 
to me. I found the bones displaced backward about three-quarters of an inch, 
and half an inch outward, or to the fibular side. This was the position of the 
bones when he was sitting with his leg bent at a right angle with the thigh, but 
when he stood erect and bore some weight upon the foot, the outward displace- 
ment ceased, and the backward displacement only remained. It was very easy, 
however, in whatever position the leg might be, to push the bones forward by 



1 Fergusson op. eit., p. 284. 



Malgaigne, op. cit., torn. ii. p. 956. 



DISLOCATIONS OF TIBIA FORWARD AND INWARD. 7b7 

the hands until nearly all deformity had disappeared. He could flex the leg to 
a right angle with the thigh, and straighten it completely, but he could not lift 
the foot and leg from the floor while sitting with his limb extended in front of 
him. He was unable to bear sufficient weight upon his foot to use it at all in 
progression, on account of the inability to fix and steady the limb, but not on 
account cf any pain or soreness which it occasioned. 

Thomas Wells, of Columbia, South Carolina, has described a similar accident, 
the tibia being dislocated outward and backward, which terminated fatally on 
the fourth day in consequence mainly of exposure, intemperance, and neglect to 
apply for surgical aid. The bones were never reduced, and the autopsy dis- 
closed also a fracture of the internal condyle of the femur. 1 

§ 6. Dislocations of the Head of the Tibia Forward and Outward. 

Duvivier, 2 in 1828, treated an officer who had fallen from his horse, causing a 
dislocation of the tibia forward and outward, which was accompanied with a 
shortening of six inches. Reduction was effected, and at the end of a year the 
motions of the joint were only partially restored. 

In a case reported by Wathen 3 the reduction was easily effected, but inflam- 
mation of the joint ensued, and the cure took place with fibrous ankylosis. 

§ 7. Dislocations of the Head of the Tibia Forward and Inward. 

M. J. Cloquet 4 met with an example of simple complete dislocation of 
the head of the tibia forward and inward, which had existed one year, 
and upon which the patient could bear the weight of his body. This 
latter circumstance led Malgaigne to express a doubt as to whether it 
might not have been only a subluxation ; a supposition, however, which 
cannot be entertained if Cloquet was correct in saying that the limb was 
shortened one inch and a half. 

Gerdy 5 met with a case of complete dislocation, the limb being shortened half 
an inch, slightly flexed, and immobile. The popliteal artery was compressed. 
Eeduction having been effected, the patient was able on the twenty-first day to 
walk very easily. 

In a case reported by Sir Astley Cooper the dislocation was accompanied with 
a tearing of the integuments, and the limb was amputated. Dissection disclosed 
a large laceration of the vastus externus, and of the capsule and ligaments pos- 
teriorly. The lateral and crucial ligaments were unbroken. 

In a case seen by Malgaigne 6 the displacement was incomplete. 

W. Mulligan 7 reports a case of complete dislocation in the person of a man 26 
years old caused by a direct blow upon the anterior and internal part of the 
thigh. The injury seemed simple and the integuments were intact. Reduction 
was effected easily by flexion, but it was then noticed that arterial pulsations in 
the foot had ceased, and a little later the appearance of gangrene in this portion 
of the limb rendered amputation necessary. 

Treatment. — Malgaigne says " the dislocation may be reduced by 
direct extension, as in the case of outward dislocations, but it may be 
found a little more difficult; Gerdy employed three assistants, but I em- 

1 Wells. Araer. Journ. Med. Sci., vol. x. p. 25, May, 1832. 

2 Duvivier, Malgaigne. from Arch. Gen. de Med.,"l829, t. 20, p. 292. 

3 Wathen, Poinsot, Med. Times and Gaz., Nov. 23, 1872. 
* Cloquet, Die. de Med., Art. Genou. 

5 Gerdy, Arch. Gen. de Med., 1835, t. 13, p. 163. 

6 Malgaigne, op. cit., vol. 2, p. 959. 

7 Mulligan, Med. Press and Circular, Sept. 15, 1S75. 



768 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

ployed only two. The pressure applied to the tibia by resting the femur 
upon the knee,. did not prove to be sufficient," and it became necessary 
to employ a more solid resistance, and to substitute a block of wood for 
the operator's knee. Gerdy's case was a complete dislocation, while 
Malgaigne's w r as incomplete. Sir Astley experienced great difficulty in 
the reduction ; and the dislocation having at once been reproduced, 
amputation was practised. 

§ 8. Dislocations of the Head of the Tibia by Rotation. 

Rotation sometimes accompanies either of the preceding dislocations ; 
but I speak now of examples in which the dislocation is by rotation 
alone. 

Malgaigne 1 has cited the following examples : In the case of Dubreuil, 2 which 
was presented in the service of Malgaigne himself, the leg was extended and 
rotated outward until the head of the fibula projected in the popliteal space, and 
the patella, dragged by the tibia, was completely dislocated outward. The dis- 
location was reduced two hours after the accident by a single assistant, who 
grasping the upper portion of the leg with both hands, made light traction and 
rotated the limb from without inward. Nineteen months after the accident the 
knee was stiff, painful, and incapable of supporting the body. 

Boursier, 3 of Bordeaux, published an example of this form of dislocation which 
occurred in a person set. 19. When admitted to the hospital the leg was slightly 
flexed and rotated outward. There was no discoloration or swelling. The 
patella was lodged upon the external condyle. Attempts at reduction by ex- 
tension and rotation were unsuccessful ; but on placing the patient under the 
influence of chloroform the reduction was easily effected by the same man- 
oeuvres. Codman and Petrequin have each reported one example of outward 
rotation seen in autopsies. 

Malgaigne cites also a case reported by M. Paris 4 of dislocation by rotation 
inward, the internal condyle of the tibia resting behind the internal condyle of 
the femur. Reduction was easily effected, but a chronic arthritis ensued. 

§ 9. Internal Derangement of the Knee-Joint. 

Syn. — " Slipping of the semilunar fibro-cartilages ; " Hey. "Partial dislocation of the 
thigh-bone from the semilunar cartilages; " Sir Astley Cooper. " Subluxation of the semi- 
lunar cartilages; " Malgaigne. " Subluxation of the knee ; " Erichsen. To these I think 
it proper to add, as giving rise to the same class of symptoms, '" Floating cartilages in the 
knee-joint." 

This accident is in no proper sense a subluxation of the knee. I 
should not make any farther allusion to it, were it not necessary in order 
to enable the student of surgery to distinguish between the phenomena 
which belong to it and those which belong strictly to subluxation of this 
joint. 

Symptoms.— The patient is suddenly thrown to the ground while 
walking, as if by an instantaneous loss of power in the affected limb, this 
loss of control over the limb being accompanied usually with sharp pain, 
referred to the region of the knee-joint; or he trips his toe against some- 

1 Malgaigne, op, cit., vol. 2, p. 962. 

2 Dubreuil, Arch. Gen. de Med.. 1852, t. 30, p. 251. 

3 Boursier, Journ. de Med., Bordeaux, Dec. 31, 1882, p. 225. 

4 Paris, Malgaigne, from Bev. Med.-Chir., vol. 12, p. 174. 



INTERNAL DERANGEMENT OF THE KNEE-JOINT. 769 

thing in his path, and the toes becoming everted, the leg suddenly gives 
way under him ; in some cases it has happened when the patient was 
turning in bed, the weight of the bedclothes hanging upon the toes so as 
to occasion a strain and rotation outward at the knee-joint, or it follows 
upon a subluxation of the joint, as in one example which I shall presently 
relate; or it may result from forced flexion of the knee. If the patient 
is walking when the accident takes place, and he falls to the ground, he 
finds himself unable to move the limb, or to stand upon it; but by man- 
ipulation or extension, the difficulty is, in most cases, as easily overcome 
as it occurred, when immediately the motions of the joint become free, 
and he walks off as if nothing had happened. When the accident has 
once taken place, it is afterward exceedingly liable to occur from very 
slight causes, and eventually the knee-joint becomes tender and the cap- 
sule fills with synovia, indicating the existence of subacute synovitis. 

A man, set. 23, consulted me, on the 27th of October, 1858, in relation to 
the conditionof his knee-joint. He stated that on the 13th of August, 1858, 
while standing with the whole weight of his body resting upon the left leg, a 
mate struck him on the inside of the lower end of the left femur. The blow was 
made with the palm of the hand, but with sufficient force to throw him down. 
It was immediately noticed that the tibia was partially dislocated inward at the 
knee-joint. The. whole lower part of the limb was inclined outward. A person 
present in the room seized upon the foot and by extension easily brought it back 
to place; the bone resuming its position with an audible snap. After this he 
continued to walk about until night. Two days after, the knee had become so 
much inflamed that he was obliged to take to his bed, on which he was confined 
three weeks. Gradually the swelling subsided, and in about five weeks after the 
accident he began to walk on crutches. On the 23d of September he was walk- 
ing in the store without crutches, when he suddenly felt a sensation of slipping 
in the joint, and he fell to the floor as if he had been tripped up. At the time 
when he called upon me, this had happened many times, but had never been 
attended with pain. The joint was filled with synovia, and tender, yet I could 
distinctly feel a hard body just to the inside of the ligamentum patellae, and 
which moved freely under the finger. 

Prof. Le Fort 1 has described this accident as it occurred in his own person, in 
consequence of a forced flexion of the leg. He was conscious at the time of a 
movement in the joint at the external part of the right knee, and when he arose 
he found the limb fixed in the position of flexion, and he was only enabled to 
straighten it by a violent muscular effort, the effort being accompanied by a 
violent pain, and a very loud crack, as if something which was displaced had 
resumed Its place. Immediately all pain disappeared and the motions of the 
joint were restored. For several months the accident was repeated whenever 
the knee was much flexed ; the phenomena attending the displacement being in 
in each case the same as at first, he having always a distinct recognition of the 
movement of displacement, and always the voluntary straightening of the limb 
reproduced the crack, and caused the pain to cease. By avoiding the causes the 
accident ceased to occur; but after a time he failed to exercise the same caution, 
and the accident again occurred ; but this time the displacement of the cartilage 
was backward instead of forward, as it had been previously, and the straighten- 
ing of the limb caused an atrocious pain, which lasted, in some degree, more 
than eight days. He has since then exercised the same caution as before, and 
the displacement has not recurred. 

Pathological Anatomy. — The same class of symptoms, with only very 
slight modification, belongs probably to several varieties of " internal 
derangement of the knee-joint;" and first it will be remembered that the 

1 Le Fort, Bull. Soc. Chir., Paris, 1879, July, 2. 
49 



770 DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

semilunar cartilages upon which the margins of the condyles of the femur 
rest, are attached to the tibia by several ligaments ; but when, from relax- 
ation or a violent strain, any one of these ligaments becomes elongated 
or gives way, the portion of cartilage which it restrains is permitted to 
become partially displaced, and by interposing its thick margin between 
the deeper articulating surfaces the bones are separated and the muscles 
lose their control over the joint ; second, these ligaments may not only 
yield, but a fragment of one of the cartilages may become actually 
broken off from the main portion ; third, the femur may perhaps escape 
behind some portion of an interarticular cartilage, and thus, instead of 
the cartilage placing itself between the joint surfaces, the femur itself 
may have thrust it into this position ; fourth, a cartilage, or some portion 
of a cartilage, may become hypertrophied, and thus give rise to the 
symptoms described ; fifth, in other cases still, a bony, cartilaginous, 
fibrinous, or calcareous growth or concretion forming within the joint, 
and, if originally attached, becoming separated from the capsule, may 
move about more or less freely, and give rise to the same class of symp- 
toms which I have described. This last variety has generally been 
described under the name of " floating cartilages;" but since these bodies 
are not always cartilaginous, and especially since they do not always by 
any means move so freely as to be properly designated as " floating," the 
term is less appropriate than that originally given by Hey, and which I 
have chosen to adopt. 

Treatment. — For the purpose of obtaining immediate relief, it is gener- 
ally sufficient to flex the leg completely and then suddenly extend it, or 
to combine this motion with a slight twisting or rocking of the knee-joint. 
Sometimes this experiment has to be repeated several times before it is 
completely successful, and in a few instances it has failed altogether. I 
think I must have met with ten or twelve examples in the course of my 
practice, and in no instance have the sudden flexion and extension of the 
limb failed to overcome the difficulty. As to the question of subsequent 
treatment, especially as to whether it is proper to attempt extirpation of 
the cartilages when they are found to be actually floating, or to make any 
other surgical interference, I prefer to leave its consideration to those 
general treatises upon surgery where it more properly belongs. 



CHAPTER XX. 

DISLOCATIONS OF THE LOWER END OF THE TIBIA 
(TIBIO-TARSAL). 

Syn.—" Dislocations of the ankle-joint;" Chelius and others. 

The tibia may be dislocated at its lower end in four directions ; namely, 
inward, outward, forward, and backward. Most of these dislocations 
complicate themselves with fractures of the fibula or of the tibia, or with 
fractures of both bones. 



DISLOCATIONS OF LOWEK END OF TIBIA INWARD. 771 

Dupuytren, Malgaigne, and a few other surgeons have reperted examples also 
of dislocations forward and inward. Boyer, with a majority of the French 
writers, and several English and German surgeons, speak of these dislocations 
as belonging to the foot ; consequently the outward dislocation of Boyer is the 
inward dislocation of Sir Astley Cooper, Malgaigne, myself, and others, who 
prefer to regard the tibia as the bone dislocated. 



§ 1. Dislocations of the Lower End of the Tibia Inward. 

Syn.—" Inward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot outward j" 
Boyer and others. 

Causes. — This dislocation is occasioned generally by a fall from a 
height, upon the bottom of the foot, the foot receiving at the same moment 
a sufficient inclination outward to determine the main force of the impulse 
toward the inner side of the ankle. It may be produced also by a blow 
received directly upon the outside of the leg just above the ankle, or by 
a violent twist or wrench of the foot outward. 

Pathological Anatomy. — A large majority of those accidents which 
have been called inward and outward dislocations of the tibia, are merely 
examples of lateral rotation of 

the astragalus within the half Fig. 490. 

ginglymoid and half orbicular 
socket formed by the lower ex- 
tremities of the tibia and fibula ; 
and true dislocations, either par- 
tial or complete, are at this joint 
and in these directions very rare 
occurrences. I shall continue, 
in accordance with the general 
practice of writers, to call them 
all dislocations, whether the as- 
tragalus simply rotates on its 
axis, or is displaced laterally 

and horizontally from the tibia. Dislocation of the lower end of the tibia inward 
In the most Common form of (foot turned outward). (Pott's fracture.) 

the accident, then, when the foot 

is violently twisted outward, the astragalus becomes tilted upon its outer 
and upper margin in such a way that this margin slides inward and 
places itself underneath the middle portion of the lower articulating 
surface of the tibia ; its upper and inner margin descends toward the 
extremity of the malleolus internus, and the outer surface of the astragalus 
presents obliquely upward and outward, instead of directly outward as it 
would do in its natural position. This cannot occur without a rupture 
of the internal tibio-tarsal ligaments, or a fracture of the malleolus 
internus, or both ; indeed, a fracture of the internal malleolus is a very 
common circumstance in connection with this form of dislocation. Much 
more frequently, however, the fibula itself gives way at a point within 
from two to five inches of its lower extremity ; or sometimes the fracture 
in the fibula occurs through that portion which forms the malleolus 
externus. For more particular information as to the causes and relative 




772 DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

frequency of these fractures, I refer the reader to the chapter on frac- 
tures of the fibula. 

Rarely it happens that, instead of this lateral rotation of the astragalus, 
there occurs a true lateral displacement of the tibia inward upon the 
astragalus, and the outer portion of the lower articulating surface of the 
tibia comes to rest upon the inner portion of the upper articulating sur- 
face of the astragalus ; or it may slide completely off in the same direc- 
tion ; a result which is usually attended with a laceration of the muscles 
and integuments, converting the accident into a compound dislocation. 
In some cases this extreme displacement occurs without such laceration. 
In this form of the accident, the true lateral dislocation, the fibula may 
remain unbroken and undisturbed, the tibia merely having become dis- 
placed inward ; or the fibula may give way also above the articulation, 
while the malleolus internus, and the internal lateral ligaments, are 
equally liable to rupture as in the other form of the accident. Some- 
times, in addition to these complications, the lower end of the tibia is 

Fig. 491. 




Dislocation of the lower end of the tibia inward (foot turned outward). 



found to be broken obliquely upward and outward from the articulating 
surface, leaving that fragment attached to the fibula which corresponds 
to the inferior peroneo-tibial articulation. 

Symptoms. — The loot is more or less violently abducted, the sole of 
the foot presenting downward and outward instead of directly downward ; 
the malleolus internus projects strongly at the inner side of the joint: 
and at the outer side there is a corresponding depression, generally most" 
marked a little above the articulation near the point of fracture in the 



DISCOCATIONS OF LOWER END OF TIBIA INWARD. 773 

fibula. The pain is very great, and the foot is immovably fixed so far 
as the volition of the patient can determine motion, but the surgeon can 
generally move it pretty freely, yet not without causing a great increase 
of the pain. When the dislocation is complete, and the fibula is also 
broken, the limb becomes slightly shortened. 

Treatment. — When the accident is of the nature of a simple rotation 
of the astragalus upon its axis, the reduction is often accomplished with 
the greatest ease by seizing upon the foot and forcibly adducting it. Not 
unfrequently the patient himself, or some other person who is present, 
has effected the reduction before the surgeon is called. In other cases, 
and especially when it partakes of the nature of a true dislocation, much 
difficulty is sometimes experienced in the reduction. The surgeon ought 
then to flex the leg upon the thigh, in order to relax the gastrocnemii 
muscles, and holding the foot midway between flexion and extension, he 
should pull steadily upon it with his own hands, while an assistant makes 
counter-extension and supports the limb with his hands, grasping the 
thigh above the knee. At the same moment lateral pressure should he 
made upon the projecting bone in the direction of the articulation. It 
is of some use, also, occasionally to flex and extend the limb moderately, 
and to give to the foot a gentle rocking motion. If more force is needed, 
it may be applied by placing the limb over a firm double-inclined frac- 
ture-splint, and making the extension by the aid of a screw attached to 
the foot-board, as I have suggested in certain cases of dislocation at the 
knee. Or we may employ the pulleys after the manner represented in 
the accompanying drawing, Fig. 492. 

C. S., aged about 30 years, while carrying a weight upon his shoulders, on 
the 6th of May, 1854, slipped upon the sidewalk, and fell, dislocating the left 

Fig. 492. 




tibia inward, and fracturing the fibula four inches from its lower end. I was in 
attendance soon after the accident occurred, and found the tibia projecting 
inward, with the other symptoms usually accompanying a simple rotation of the 
astragalus upon its axis. Seizing the foot with my hands and flexing the leg, 
while an assistant held the thigh and made counter- extension, I had scarcely 
begun to pull upon the foot before the reduction was effected. Dupuytren's 
splint was at once applied, and the subsequent inflammation was so trivial as 
scarcely to deserve notice. In six weeks the limb was sound, and free from all 
ankylosis. 



774 DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

In my report on dislocations, made to the New York State Medical Society 
for the year 1855, 1 have mentioned twelve similar examples, in addition to some 
examples of compound dislocations, all of which were easily reduced, but the 
results were not always so favorable. 

If, as rarely happens, the tibia is broken obliquely into the joint, the 
complete reduction of the dislocated tibia may be found impossible, owing 
to the obstacle presented by the displaced fragment. 

The following I am disposed to regard as examples of dislocation accompanied 
with fracture of the tibia within the articulation : Brockway, of Cortland, N. Y., 
aged about twenty-seven years, consulted me in relation to the condition of his 
foot. I found the tibia dislocated inward, and projecting more than an inch 
beyond the astragalus ; the sole was turned outward, compelling him to walk 
upon the inside of his foot ; the fibula was bent inward against the tibia, at a 
point about four inches above the ankle, which seemed to have been the seat of 
fracture of this bone. He stated to me, that immediately after the receipt of 
the injury, which was occasioned by a fall from a height upon the bottom of his 
foot, a surgeon made repeated and violent efforts to effect the reduction, but he 
had been unable to do so. Indeed, the bone had never been removed from the 
position in which it was at first placed. 

J. B., of Erie Co., N. Y., set. 31, fell under a rolling log, and dislocated his 
left tibia inward, breaking off the internal malleolus, and fracturing the fibula 
four inches from its lower end. An old and experienced practitioner was imme- 
diately called, who, with another surgeon, failed, after repeated efforts, to reduce 
the dislocation. I saw the patient, in consultation with these gentlemen, twenty- 
four hours after the accident. The foot and ankle were somewhat swollen and 
discolored. The lower end of the tibia projected so far inward as to threaten a 
rupture of the skin ; the foot was strongly everted. We first flexed the leg upon 
the thigh, and made extension with our hands, in the manner I have already 
directed. This we continued several minutes ; finally moving the limb in various 
directions, and adding forcible pressure upon the inside of the projecting tibia. 
We then placed the leg over a double inclined plane, and, securing it firmly in 
place, we attached a screw to the foot through a sandal and gaiter, and while 
the leg was well flexed upon the thigh, we renewed the extension and lateral 
pressure. This was continued, with the application of more or less power, 
during half an hour, meanwhile changing the position of the limb occasionally 
by varying the angle of the splint. Our efforts were prolonged in all more than 
one hour, when, as we had made no impression upon the bone, and the patient 
had repeatedly implored us to desist, the attempt was given over. The end of 
the tibia seemed to rest partly upon the astragalus, and the extension was plainly 
all that was demanded, but the obstacle was beyond doubt within the articula- 
tion, or rather between the tibia and fibula. 

Four weeks after the accident, Mr. B. walked on crutches, and during a year 
he was compelled to use a cane, but since that time, a period of twelve years, he 
walked without any artificial support. For a year or two he felt a yielding in 
his ankle, as the weight of his body settled upon his limb ; but this gradually 
ceased, and for some years past he has walked without any halt, and seems to 
step as firmly as before the accident. The foot still inclines outward ; the tibia 
projects inward one inch, and the broken ends of the fibula can be felt resting 
against the tibia, where they are reunited. 

I had occasion to amputate a limb for a compound dislocation inward, 
at the ankle-joint, and the possibility of this fracture was confirmed by 
the dissection. About one-third of the outer portion of the articular 
surface was broken off obliquely, and the fragment was lying so displaced 
that a reduction would have been rendered impossible. 

Dr. Townsend, of Boston, has reported a case of compound dislocation, in 
which also amputation became necessary ; and, with other injuries, the dissec- 



DISLOCATIONS OF LOWEE END OF TIBIA OUTWARD. 775 

tion showed a fragment from the outer margin of the tibia, one inch and a half 
long, and one inch thick at its widest part, with a very sharp point, displaced, 
and lying almost transversely over the astragalus. 1 

In 1842, A. Berard, 2 in order to effect reduction, divided subcutane- 
ously the tendo-Achillis, and at the same time the peroneus longus and 
brevis. Valentin 3 reports a case of dislocation forward and inward, which 
had resisted all efforts. Tractions made by three strong assistants, while 
the patient was under the influence of chloroform, and at two different 
days, had produced no result. Valentin divided the tendo-Achillis, and 
was then able to reduce the dislocation alone, and without the employ- 
ment of excessive strength. The patient recovered with a restoration of 
the natural motion of the foot. 



For a more full account of the prognosis and the general management of these 
cases subsequent to the reduction see the chapter on fractures of the fibula ; 
and for the treatment of compound 

dislocations of the ankle-joint, see Fig. 493. 

also the chapter on compound dislo- 
cation of the long bones. 

§ 2. Dislocations of the Lower 
End of the Tibia Outward. 

Syn. — " Outward tibio-tarsal disloca- 
tion;" Malgaigne. " Dislocations of the 
foot inward," of others. 

The causes are the same or 
similar to those which are known 
generally to produce dislocations 
inward; only that the force of 
the concussion or the direction of 
the rotation must have been re- 
versed. The external lateral liga- 
ments, peroneo-tarsal, are either 
ruptured, or the lower portion of 
the fibula gives way, or both of 
these circumstances may have hap- 
pened ; while the internal malle- 
olus may also yield to the shock 
and to the weight of the body 
now resting upon it. The nature 
of the accident may vary also in 
respect to the relative position 
of the articular surfaces ; the 
astragalus may simply rotate on 
its inner and upper margin, or 
the tibia, with the fibula, of 
course, may actually slide outwarc 
or less completely abandons the upper surface of the astragalus. 

1 Townsend, Mass. Hosp. Reports, Boston Med. and Surg. Journ., vol. xxxiii. p. 277. 

2 Berard, The Lancet, 1844, vol. i. p. 8. 

3 Valentin, These de Strasbourg, 1866, No. 970; Arch. Gen de Med., t. 1. 1867. 




Dislocation of the lower end of the tibia out- 
ward (foot turned inward). 

until the lower end of the tibia more 



776 DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

Treatment.— The modes of reduction, and the general principles of 
treatment, will not differ from those which I have mentioned as suitable 
for dislocations in the opposite direction. The examples which have 
fallen under my observation are not numerous, but the reduction has 
always been easily effected. Thus, a man, set. 21, fell from a scaffolding, 
alighting upon his feet. He says that his left foot struck the ground 
obliquely, and upon its outer margin. I found the fibula projecting very 
strongly outward, evidently carrying with it the tibia; the malleolus 
internus was broken off, and the foot forcibly turned inward. Without 
either flexing the leg upon the thigh or calling to my aid any degree of 
counter- extension except what was made by the weight of the body, I 
grasped the foot and drew upon it gently, while at the same moment I 
rotated the foot outward. Immediately the bones resumed their places. 

In June of 1846, H. W., set. 38, consulted me in relation to his foot, which he 
said had been dislocated four weeks before. He had fallen upon the outside of 
his foot and turned it suddenly inward, so that when he looked at it he found 
the sole presenting toward the opposite side. Seizing upon it with both hands, 
he pressed it forcibly outward, and the reduction immediately took place with 
a snap. Very little soreness followed, nor was he confined to his house a single 
day. He had continued to walk about with only a slight halt in his gait, nor 
would he have thought it necessary to consult me at all except that the tender- 
ness had not yet disappeared. He was not aware that the fibula had been 
broken also, until I called his attention to the fact. The fracture had taken 
place two inches above the ankle; and although it was already united, the 
depression occasioned by its having fallen in somewhat toward the tibia was 
very plainly felt and recognized. 



§ 3. Dislocations of the Lower End of the Tibia Forward. 

Syn. — "Forward tibia-tarsal luxations;" Malgaigne. "Dislocations of the foot back- 
ward," of others. 

Causes. — This dislocation may be produced by a violent extension of 
the foot upon the leg ; as, for example, when, the foot being engaged 
under a piece of timber, the body falls backward to the ground ; or it 
may be caused by a fall upon the bottom of the foot, the foot resting 
upon a slightly inclined plane. It may be caused also by any of that 
class of accidents which are known to produce fractures of the fibula with 
fracture of the malleolus internus, or fracture of the fibula with rupture 
of the internal lateral ligament ; for example, by a fall upon the bottom 
of the foot, or upon the inside of the sole, followed immediately by an 
outward twist of the foot. In these cases the dislocation of the foot 
backward, or, as it is generally found to be, the semiluxation, may be 
consecutive upon the accident, and the result only of contraction of the 
gastrocnemii. It may, therefore, occur immediately after the fracture 
has taken place, or not until after the lapse of several days. 

Pathological Anatomy. — The displacement may be very slight, so that 
the end of the tibia is only a little advanced upon the astragalus ; or it 
may be such that the tibia rests one-half upon the naviculare and one- 
half upon the astragalus, or it may even desert the astragalus entirely. 
The fibula may at the same time be broken at any point, but it is gen- 
erally broken two or three inches above its lower extremity. The malle- 



DISLOCATIONS OF LOWER END OP TIBIA FORWARD. 777 

olus interims is also sometimes broken, but more often the internal lateral 
ligament is torn. Still more rarely a fracture occurs through the pos- 
terior margin of the articular surface of the tibia. 

Symptoms. — The length of the foot in front of the tibia is diminished, 
while the projection of the heel is correspondingly increased ; the toes 
are turned downward and the heel drawn upward, and fixed in this posi- 
tion ; the end of the tibia may generally be distinctly felt in front of 
the astragalus ; the extensor tendons of the toes are sharply defined, 
while the tendo Achillis is curved forward and tense. 

I presented to the New York Pathological Society a specimen obtained from 
the dissecting room of the Bellevue Hospital College. The history of the case 
was unknown. Before dissection the foot was observed to be turned outward, 
and shortened in front of the tibia, while there was a corresponding lengthening 
of the heel. The specimen, after dissection, disclosed a fracture of the internal 
malleolus half an inch above its lower end and a fracture of the fibula a little 
above its lower end. The tibia was displaced forward about three-quarters ot 
an inch, so that only the posterior half of its lower end rested upon the articular 
surface of the astragalus, and at the point of contact with the astragalus a new 
socket was formed in the tibia, concave upward, half an inch deep, and present- 
ing an appearance as if the posterior lip of the lower end of the tibia had been 
broken off and had become displaced upward. It was supported by a broad 
buttress of bone. It is not certain, however, but that this appearance was occa- 

Fm. 494. Fig. 495. 








Partial dislocation of the tibia forward, Appearance of a partial dislocation of the 

with fractures of malleolus internus and tibia forward, with fracture of the malleolus 

fibula. Skeleton. internus and fibula. 

sioned solely by the long-continued pressure of the tibia upon the astragalus at 
this point. The fragments of the malleolus internus, and the lower fragment of 
the fibula, remained attached to their upper fragments and to the two sides of 
the astragalus in their normal positions, consequently each fragment was inclined 
downward and backward at an angle of 45°. The lower fragment of the fibula 
was driven upward, also, but both of the fractures were firmly united. 

At the same meeting I reported the case of Mary Conlan, set. 38, having been 
thrown, three days before, from a street-car. She could give no account of the 
manner in which she fell. I saw her November 16th. The limb was then much 
swollen, and I diagnosticated a fracture of the lower end of the fibula. (It had 
been supposed to be a mere sprain up to this time.) The limb was directed to 
be wet with cool water, and to rest upon a pillow. November 23d I found the 
lower end of the tibia displaced forward, and ascertained, also, that the internal 
malleolus was broken at its base. The dorsum of the foot, measuring from the 



778 DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

front of the tibia to the end of the great toe, was shortened half an inch. The 
heel was lengthened. There can be no doubt that in this case the dislocation 
occurred subsequent to the fracture, and that it was caused by the contraction 
of the gastrocnemii. I reduced the dislocation a day or two later, and main- 
tained it in position by the method which I shall presently describe. 

Dr. Voss reported to the Society a similar case which had come under his 
notice, and Dr. Buck remarked that he, also, had met with such examples. 1 

Dr. Prince, of Illinois, has reported a case of this character which, remaining 
displaced, led to a prosecution for damages. A lady, set. 40, met with an acci- 
dent, August 31, 1863, which resulted in a fracture of the fibula near its lower 
end and a partial dislocation of the tibia forward to the extent of one inch. 
The toes were not pointed downward, but the foot had its natural angle with 
the leg. Nearly three months after the accident Dr. Prince, assisted by two 
other surgeons, broke up the adhesions, and reduced the bones to their natural 
positions.' 

Treatment. — The reduction is to be attempted by flexing the leg 
upon the thigh, and making extension from the foot, while at the same 
moment pressure is made upon the front of the tibia and against the heel. 
When the bone begins to slide into place, the foot should be forcibly 
flexed upon the leg. A slight lateral motion or rotation in either direc- 
tion may assist in restoring the bones to place. In general, the disloca- 
tion has been easily reduced, but in a majority of the examples recorded 
great difficulty has been experienced in maintaining the reduction ; and 
in a few cases it has been found impossible to do so. In order to main- 
tain the reduction, the leg, flexed upon the thigh, may be laid on its 
back in a box, and the foot supported firmly against a foot-piece placed 
at a right angle with the box. In this position the weight of the leg 
will tend somewhat to overcome the action of the muscles, which are dis- 
posed to displace the foot backward. Generally it will be found neces- 
sary to make additional pressure directly upon the front of the leg above 
the ankle, which, in order that it may not prove mischievous, must be 
effected with some soft material, and must be applied over a broad sur- 
face. Perhaps nothing will better answer these indications than to pass 
a cotton band, six or eight inches in width, through slits or mortises in 
the sides of the box, these slits being of a width equal to the width of 
the band and placed at a point sufficiently below the level of the spine 
of the tibia, so that when the band is made fast underneath the box, it 
shall press the leg firmly backward. To prevent the heel from suffering 
in consequence of this pressure, it also should be supported, or suspended 
by another band passing underneath the heel and fastened above to the 
top of the foot-board. 

The plaster-of-Paris dressing, also, answers the purpose exceedingly 
well in these cases ; indeed, as I have explained more fully in connec- 
tion with the subject of Pott's fracture, I must regard it as the most 
effective means for preventing these accidents, as sequences of this frac- 
ture, and as the most certain means for retaining the bones in position, 
w T hen, the displacement having actually occurred, they are again put in 
place. 

1 New York Journ. Med., April, 1866, p. 40. 

2 Cincinnati Journ. Med., April, 1867, p. 202. See also Todd's Cyclopaedia of Anat. and 
Phys. ; Adams on Ankle-joint, p. 160 et seq. 



DISLOCATIONS OF LOWER END OF TIBIA BACKWARD. 779 

Dupuytren relates the following example of this accident : Pierre Froment, 
ast. 33, was carrying a heavy weight upon his back and had his right foot in 
advance, when by accident he came suddenly in contact with a beam placed 
across his path. Under the fear of being precipitated forward, he made a sud- 
den effort to throw his body backward, by which he lost his balance, and fell 
with the point of the left foot inclined inward and forward, and his whole weight 
was thrown first on the outer side and then on the front of the ankle-joint. On 
examination, the leg seemed to be planted upon the middle of the foot; the toes 
were directed downward and the heel drawn up. On the instep there was a 
large bony prominence, over which the extensor tendons of the toes were 
stretched like tense cords. Behind the joint was a deep hollow, at the bottom 
of which the tendo Achillis could be felt forming a tense, resisting, semicircular 
cord, with its concavity directed backward. The fibula was also broken, the 
lower end of the lower fragment remaining attached to the foot, while the upper 
end of the same fragment was carried forward by the displacement of the tibia, 
so that it lay nearly horizontally, with its broken extremity directed forward. 
Dupuytren directed one assistant to fix the leg and a second to make extension 
from the foot, while Dupuytren himself, standing on the outer side of the limb, 
forced the heel forward and the tibia backward. The first attempt succeeded 
partially and the second completed the reduction. The limb was then placed 
in the apparatus employed by this surgeon for a fractured fibula, which I have 
before described, and laid on its outer side in a semiflexed position. The patient 
recovered rapidly, and in little more than a month he was able to walk. 1 

But such fortunate results have not usually been observed ; indeed, Dupuytren 
encountered much more serious difficulties in two other cases which came under 
his own notice, one of which he has himself recorded. This was in the person 
of a woman, set. 48, who was brought to l'Hotel Dieu in 1815, the accident hav- 
ing just happened from a slip in going down stairs. The fibula was broken, and 
also a fragment was broken from the tibia. The house surgeon reduced the 
bones, and placed the limb in the ordinary apparatus for broken legs ; but on 
the following day Dupuytren found them redislocated, and laid the limb on his 
own splint, but the pressure requisite to keep the tibia in place soon induced 
sloughing, ulceration, and abscesses, and after four months' treatment, during 
which time the tibia had been repeatedly displaced, she left the hospital, able 
to use her limb, but with a certain amount of incurable deformity. 1 Malgaigne 
mentions the third example as having been seen by himself in Dupuytren's 
service in 1832, in which case the attempt to maintain the reduction by a tourni- 
quet resulted in gangrene and finally the death of the patient. 2 Earle lost a 
patient after amputation made on the eighth day. The tibia could not be kept 
in place, and the amputation became necessary on account of the final protru- 
sion of the bone through the integuments, which had sloughed. 3 Reginald 
Harrison, 4 who had seen three cases of this dislocation, practised section of the 
tendo Achillis for the purpose of maintaining the tibia in place, and with com- 
plete success. 



§ 4. Dislocations of the Lower End of the Tibia Backward. 

Syn. — "Backward tibio-tarsal dislocation:" Malgaigne. ''Dislocations of the foot for- 
ward," of others. 

More rare than the dislocations forward, Malgaigne has, nevertheless, 
succeeded in collecting five examples. They appear to have been pro- 
duced, generally, by a cause the reverse of that which we have seen to 
produce in certain cases the preceding dislocation. Thus, while the dis- 
location forward is produced sometimes when the foot is in violent exten- 

1 Dupuytren, op. cit., p. 276. 2 Malgaigne, op. cit., p. 1044. 

3 Malgaigne, op. cit., p. 1044. * Harrison, The Lancet, 1876, vol. i. p. 707. 



780 DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

sion, this dislocation has occurred, in at least two or three cases, when 
the foot was forcibly flexed upon the leg. 

The symptoms are strongly marked and characteristic. The length of 
the foot from the tibia to the ends of the toes is increased one inch or 
more, the head being correspondingly shortened, or rather wholly obliter- 
ated; a portion of the articulating surface of the astragalus may be dis- 



Fig. 496. 



Fig. 497. 





Dislocations of the lower end of the tibia backward. 



tinctly felt in front of the tibia ; the posterior surface of the tibia touches 
the tendo Achillis ; the leg is shortened, and the malleoli approach the 
sole of the foot. In most cases one or both of the malleoli have been 
broken ; and R. W. Smith, who has reported one of the examples alluded 
to, believes that the dislocation is never complete. 

A similar case came under the observation of Dr. S. B. Ward, of Albany, 
N. Y., in November, 1882. The patient had fallen from a scaffold, and Dr. 
Ward found him with a fracture of the internal malleolus and a dislocation of 
the tibia backward, the signs of which were characteristic and marked. Reduc- 
tion was easily effected, and was accompanied with an audible snap. There was 
no apparent tendency to a recurrence of the dislocation, and there resulted 
finally a complete restoration of the motions of the ankle-joint. Another case 
is reported by M. Poland, in Guy's Hospital Reports for 1855. 

Reduction should be attempted by a method similar to that which has 
been recommended in all the other dislocations of the ankle, only with 
such modification as the peculiarities of the case must necessarily suggest. 



DISLOCATION'S OF UPPER END OF FIBULA FORWARD. 781 



CHAPTEE XXI. 

DISLOCATIONS OF THE UPPER END OF THE FIBULA. 

Syn. — " Dislocations of the superior peroneo-tibial articulation;" Malgaigne. 

Surgeons have frequently described a condition of the peroneo-tibial 
articulation in which the ligaments have become relaxed, giving a pre- 
ternatural mobility to the head of the bone. It is also not unfrequently 
displaced upward, in consequence of an oblique fracture of the tibia. I 
have myself seen several examples of both these accidents ; but simple 
traumatic dislocations, which can only occur forward or backward, are 
very rare (Boyer 1 relates a case in which both the upper and lower pero- 
neal extremities were dislocated, and the foot dislocated outward). 

§ 1. Dislocations of the Upper End of the Fibula Forward. 

Malgaigne has collected three examples of this dislocation, observed bv 
Savournin, Jobard, and Thompson, respectively, uncomplicated with any 
other accident; and not, apparently, due to any abnormal condition of 
the ligaments ; two of which, at least, seemed to have been produced bv 
the violent action of the muscles which, arising from the anterior face of 
the fibula, traverse below the anterior surface of the foot. The third 
example, reported by Thompson, permits a doubt as to whether the dis- 
placement was occasioned by muscular action, or by a direct blow upon 
the part. 2 

The signs which characterize the anterior dislocation are the absence 
of the head of the fibula from its natural position, and its presence in 
front, near the ligamentum patellae ; the altered direction of the biceps 
flexor cruris muscle ; and, in one case, considerable deformity in the 
shape and position of the leg has been observed. 

Thompson and Jobard 3 were unable to accomplish the reduction while the leg 
was extended upon the thigh, but succeeded readily after having flexed the leg. 
In Thompson's case the bone returned with a distinct crepitus. Savournin's case 
is related by Goyrand 4 from memory. A woman, set. 35, in falling caught her 
right foot, turning it violently inward. Savournin was called at once. He 
flexed the leg violently, in order " to relax the muscles going from the anterior 
face of the fibula to the dorsal surface of the foot," and then easily pushed the 
bone in its place with his fingers. The patient was kept in bed eight days, 
no dressings or splints being applied, and on the twelfth day she was dismissed 
cured. Malgaigne thinks that flexion of the leg, combined with flexion of the 
foot, would render the reduction more easy. 

1 Boyer, Trait, des Mai. Chir., t. 4, p. 375. 

2 Thompson, The Lancet, 1850, vol. i. p. 385. 

3 Jobard, Eev. Med. Chir., 1853, t. 14. p. 114. 

4 Savournin, Goyrand, Clin. Chir., Paris, 1876, p. 111. 



782 DISLOCATIONS OF THE UPPER END OF THE FIBULA. 

In whatever position the limb is placed, the surgeon must rely chiefly 
upon forcible pressure made with the fingers against the front and upper 
portion of the displaced bone. 

Dr. J. Hawley, of Ithaca, N. Y., has furnished a brief account of a case which 
came under his observation : On the 29th of March, 1854, Bambak, while vault- 
ing upon the parallel bars in a gymnasium, unintentionally made a complete 
somersault, and fell with his right foot upon the edge of a plank. Dr. Hawley, 
who was immediately called,, found his right leg semiflexed and immovably 
fixed. The head of the fibula was plainly felt in front of its natural position, 
near the ligamentum patellae. The patient was suffering the most intense pain. 
Extension and counter-extension were made, and while the doctor was pressing 
with both of his thumbs upon the head of the fibula, it went into its place with 
an audible snap. The relief was instantaneous. Complete rest was observed 
for a few days, while cooling lotions were constantly applied, and within a week 
he was able to attend to his usual duties. 

§ 2. Dislocations of the Upper End of the Fibula Backward. 

Sanson has recorded one example, in which the passage of the wheel 
of a carriage across the upper part of the leg, precisely on a level with 
the peroneo-tibial articulation, ruptured the ligaments which bind the 
fibula to the tibia, and caused a displacement, which, however, seems to 
have been spontaneously overcome. Nevertheless, there remained a pre- 
ternatural mobility, permitting the fibula to be pushed easily backward 
or forward upon the tibia. 1 

Sanson did not think that a permanent dislocation could be produced 
at this joint, but that the bone would be restored to its socket inevitably 
by the strong resistance offered by the aponeurosis attached to the head 
of the fibula; and Malgaigne seems not to have considered the case 
related by Sanson as a fair example of complete backward dislocation. 
It is my opinion, however, that, considering the nature and direction of 
the force applied, and the character of the symptoms present, it ought to 
be regarded as a complete backward dislocation ; in which, however, the 
aponeurosis not being much disturbed, the bone was easily restored to its 
position and retained. 

The first unequivocal case of this dislocation, unaccompanied by other com- 
plications, is related by Dubreuil. 2 A man, set. 32, in order to save himself from 
falling, sprang suddenly, with his right leg in a position of extreme abduction, 
and at the same moment he experienced a severe pain in the region of the 
peroneo-tibial articulation. The head of the fibula was found to be thrown 
backward, and formed under the skin a marked prominence; the foot was 
thrown outward, and the whole outside of the limb became cold and numb. 
Dubreuil flexed the leg moderately, and pressing the head of the fibula from 
behind forward, the reduction was easily effected. On the following day, the 
limb having been straightened, the dislocation was found to be reproduced. It 
was again replaced, and the knee covered with a leather cap, secured moderately 
tight. After twelve days of complete rest, the knee was moved gently, and on 
the seventeenth day the patient walked with the help of a cane. For some time 
the leg had a tendency to incline outward; but in about three months the cure 
was perfectly established. It is probable that in this latter case the dislocation 
resulted from the violent action of the biceps flexor cruris. Such, at least, is the 

1 Sanson, Diet, de Med. et de Chir. pratiques, p. 274, from Malgaigne. 

2 Dubreuil, Journ de Chir., 1844, p. 214, from Malgaigne. 



DISLOCATION OF THE HEAD OF THE FIBULA. 783 

opinion of both Dubreuil and Malgaigne, and I see no reason to question the 
correctness of their theory. 

Erichsen mentions that a gentleman, 23 years old, fell in descending the Alps, 
with his leg bent forcibly under him, dislocating the head of the fibula back- 
ward. When seen by Mr. Erichsen it was found impossible to reduce it, owing 
to the tension of the biceps. He suffered no permanent inconvenience from the 
accident, except that this limb was a little weaker than the other, and he could 
not jump. 1 

Another example has been reported by Dr. Joseph G. Eichardson, resident 
physician to the Pennsylvania Hospital. John Dixon, set. 9, fell five feet and 
struck upon the outside of the left knee. When admitted to the hospital, the 
leg was partially flexed and the toes a little everted, and he was unable to flex 
or to extend the limb completely. The head of the fibula was seen three-quarters 
of an inch behind its natural position, and the biceps was felt distinctly attached. 
There was no other lesion. The reduction was easily accomplished by pressing 
with the fingers upon the inner and back part of the fibula, thrusting it out- 
ward and forward. A compress and bandage were applied, and the limb placed 
at rest. The reduction continued complete, and after a few days he was per- 
mitted to use the limb. 2 

A boy, set. 2 years, fell from a chair, and on examination two weeks later, the 
doctor found the head of the fibula displaced backward. It was easily replaced, 
and without pain ; but some months later the surgeons in attendance were unable 
to retain it in place. 3 

Bryant says he has seen three examples of the backward dislocation, but gives 
no account of them. 4 

[§ 3. Displacement of the Head of the Fibula attended with Fracture.] 

[Reference has been made, in connection with fractures of the fibula, to a 
fracture near the head, with several cases (page 463). A phase of that fracture 
is found in an accompanying displacement of the head of the fibula. The 
following case, reported by Dr. A. J. McCosh, of New York, illustrates this 
injury. A man, set. 46, while in the act of lifting a horse's foot, the animal 
rolled over against the inside of his thigh, and as his leg slipped under the 
horse into a position of external adduction, he felt a pain and something give 
way on the outer side of his knee. On examination the smooth head of the 
fibula was not felt in its place, but at a point three-fourths of an inch above 
where it should be situated was distinctly felt a movable body of bony consist- 
ence about the size of a hickory nut ; this mass could be easily grasped with the 
fingers, was movable laterally, could be pushed upward for a short distance, but 
could not be made to descend toward the foot ; it was directly attached to the 
tendon of the biceps femoris muscle ; below this was a depression of three- 
quarters of an inch, and then was encountered the upper end of a bone some- 
what square and angular to the touch, which, on being traced downward, proved 
to be the fibula. It was evident that the injury consisted in a fracture of the 
upper end of the fibula, a fragment about three-quarters of an inch in length 
being drawn upward for a distance of one inch by the contracting force of the 
outer hamstring muscle. The upper fragment could not be brought directly 
down to the lower, but by flexing the knee to about 30° the separation was esti- 
mated at about half an inch. Union took place by fibrous tissue, and the patient 
was able to walk well, though the fragments separated three-fourths of an inch, 
and the upper fragment can be moved from side to side. There was no loss of 
sensation. Dr. McCosh reports a second case of fracture of the head in which 
the lower end of the small upper fragment appeared to spring away from the 
joint, and in order to bring the fractured surfaces together again pressure inward 
had to be made on the upper fragment. 5 

1 Erichsen, Science and Art of Surgery, Amer. ed., 1873, vol. ii. p. 440. 

2 Richardson, Amer. Jonrn. Med. Sci., April, 1863. 

3 St. Louis Med. and Surg. Journ., March, 1881. 

4 Bryant, Practice of Surgery, Eng. ed. of 1872, p. 810. 

5 New York Med. Eecord, Nov. 15, 1890. 



784 DISLOCATIONS OF THE LOWER END OF THE FIBULA. 

Dr. R. F. Weir, 1 of New York, in an instructive paper, reports a case of frac- 
ture and displacement of the styloid process of the head accompanied by injury 
to the external popliteal nerve. The injury occurred while wrestling and was 
due to the action of the biceps muscle. The displaced fragment was not brought 
into contact with the fibula, but the patient recovered good use of the limb.] 



CHAPTEE XXII. 

DISLOCATIONS OF THE LOWER END OF THE FIBULA. 

Syn. — " Luxations of the inferior peroneo-tibial articulation ; '* Malgaigne. 

Excepting Boyer's case of dislocation of both the upper and lower 
ends of the fibula, already referred to, Nelaton relates the only example 
of a simple dislocation of this articulation of which I have any infor- 
mation. The patient who was the subject of this accident presented 
himself at the hospital under the care of M. Gerdy on the thirty-ninth 
day after the accident, which had been occasioned by the passage of the 
wheel of a carriage obliquely across the leg in such a manner as to push 
the malleolus externus directly backward. The lower end of the fibula 
was in almost direct contact with the outer margin of the tendo-Achillis ; 
the outer face of the astragalus, abandoned by the fibula, could be dis- 
tinctly felt in nearly its whole extent ; the foot preserved its natural 
position; and he could walk pretty well, only that he was obliged to step, 
with some care. M. Gerdy believed that the bone was too firmly fixed 
in its new position to be moved, and therefore made no attempt at reduc- 
tion. 



CHAPTEE XXIII. 

TARSAL DISLOCATIONS. 
§ 1. Dislocations of the Astragalus. 

Syn. — "Double dislocations of the astragalus/' Malgaigne. 

The astragalus may be dislocated forward, outward, inward, backward ; 
or it may be dislocated obliquely in either of the diagonals between these 
lines ; it may be simply rotated upon its lateral axis, without much, if 
any, lateral displacement ; and, finally, it has been occasionally driven 
between the tibia and fibula, tearing away the intermediate ligaments, and 
generally fracturing one or both bones of the leg. 

Causes. — The causes which have been found chiefly operative in the 

1 New York Medical Journal, vol. xlvii. 1888. 



DISLOCATION'S OF THE ASTRAGALUS. 



785 



Fig. 498. 





production of this dislocation are very much the same as those which pro- 
duce, under other circumstances, a dislocation of the lower end of the 
tibia. Thus, a fall from a height upon the bottom of the foot, accom- 
panied with a violent ab- 
duction, adduction, flexion, 
or extension, may deter- 
mine a dislocation of the 
astragalus inward, outward, 
backward, or forward. 
Sometimes it is accom- 
plished by a mere wrench- 
ing or twisting of the foot 
in machinery, or in the 
wheel of a carriage, or by 
being caught between two 
irregular bodies. It may 
be produced also by a 
direct blow. 

Symptoms. — The great prominence occasioned by the displacement of 
the bone in either of these several directions, accompanied generally with 
more or less lateral deviation of the foot, is alone sufficient to indicate 
the true nature of the accident. In some cases, also, the foot is forcibly 
flexed or extended ; the leg is shortened in consequence of the tibia 
having fallen down upon the calcaneum ; the superincumbent skin and 
tendons are rendered tense ; blood is effused, and swelling speedily occurs. 
In the backward dislocation, the position of the foot is not much changed, 
but the tibia being slightly carried forward, the length of the dorsal aspect 
of the foot is proportionately diminished. To be more precise, I shall 
quote at length from the careful analysis of this subject made by Poinsot 
in the French edition of this treatise. 



Dislocation of the astragalus outward. Anatomical 
relations. 



" The dislocation forward, which is very rare, is characterized by the promi- 
nence of the astragalus on the dorsal surface of the foot, at a point corresponding 
exactly to the space midway between the two malleoli, or to the dorsal surface 
of the scaphoid bone ; that prominence is movable upon the foot and upon the 
bones of the leg. 

"In the dislocation forward and outward, the most common of all, the foot is 
in a state of strong adduction, its extremity being directed inward, and its inter- 
nal border being shortened and concave. The tibia rests upon the calcaneum, 
instead of the astragalus, and seems as if embedded in the soft parts ; the fibula 
gives rise to a marked projection on the outside. Through the stretched integu- 
ments, in front and on the outside, the articular facetta of the astragalus can be 
recognized. 

"When the dislocation has been produced forward and inward, the projecting 
astragalus is felt at that point; moreover, the foot is slightly abducted, with its 
external border elevated ; but the characteristic sign consists in the change of 
direction taken by the astragalus, whose head is directed downward, its axis 
having thus become parallel with that of the tibia. 

"The dislocation directly backward is characterized by the projection of the 
astragalus between the tibia and the tendo Achillis, which is pushed backward ; 
in addition to this diplacement backward, the astragalus undergoes a rotation 
in the direction of its transverse axis, which brings its superior surface forward 
and the inferior one backward. The tibia being slightly carried forward, the 
dorsal surface of the foot is shortened. 

50 



786 



TAKSAL DISLOCATION'S 



"In the dislocations backward and inward, or backward and outward, the pro- 
jecting astragalus is felt behind the corresponding malleolus. 

" The symptoms observed following a dislocation inward are : forced abduction 
of the foot; the existence, below the malleolus externus, of an enormous depres- 
sion, into which the integuments may be pushed ; the very marked projection 
of the internal malleolus, below which the facetta of the astragalus is felt directed 
completely inward. 

"The signs are reversed in the dislocation outward, viz. : forced abduction of 
the foot; projection of the malleolus externus, below which is the facetta of the 
astragalus turned outward ; depression below the malleolus internus. 

"The clinical history of the dislocations by rotation or by reiwersement is too 
incomplete yet to give any hope of their diagnosis being established with pre- 
cision. I will relate, however, in the way of information, what has been written 
by M. Delorme regarding the signs which, according to his statement, would 
enable one to diagnosticate the dislocations of the astragalus by renversement 
or upside down. 

"If, in the dislocation without rotation, the two bony borders of the pulley of 
the astragalus be looked for, they begin to be felt very near the head, at 1 or \\ 
centimetres from it. In the dislocations by rotation (of 180 degrees or by ren- 
versement), on the contrary, the projections by which the inferior and posterior 
articular surface of the astragalus is limited, and which were taken for the mar- 
gins of the facet, are 3J to 4 centimetres behind the head, two fingers' breadth, 
as Chassaignac has observed, who did not take advantage of this sign to estab- 
lish his diagnosis. 



Fig. 499. 



Fig. 500. 





Simple dislocation of the astragalus 
outward. 



Compound dislocation of the astragalus 
inward. 



" In dislocations without rotation, the interval separating the two bony mar- 
gins of the facet of the astragalus is 3 centimetres, measured directly over the 
bone. It would exceed 3 centimetres, but would not reach 4, on a foot covered 
by the soft parts and swollen. In dislocations by rotation, the interval separat- 
ing the projections which overhang the posterior articular surface of the astrag- 
alus is already 4 centimetres. The thickness of the soft parts and the swelling 
would increase it to nearly 5 centimetres. 

"Finally, by careful search, it would not be more difficult to feel the depres- 



DISLOCATIONS OF THE ASTRAGALUS. 787 

sion of the articular surface, between the two projecting eminences of the infe- 
rior surface of the astragalus, than to feel the flat part of the superior surface, 
which is commonly recognized in the double dislocations without rotation. At 
any rate, establishing the absence of this surface would be the acquisition of a 
valuable sign." 

Such are the symptoms which may ordinarily enable us to recognize 
the true character of these displacements when not much swelling exists, 
even though the skin is not broken and the bones are not exposed ; but 
in a majority of the examples which have been seen, the integuments 
have been more or less extensively torn, exposing to the eye at once the 
naked bone, and thus removing all chance of error in the diagnosis. 

Norris mentions a case seen by Hammersley, in which the astragalus was 
thrown completely out, and was subsequently found in the earth where the 
patient had received his injury. Inflammation, gangrene, and tetanus super- 
vened, and the patient died on the seventh day. 1 

Prognosis. — It will be readily understood that nothing short of very 
great violence- could disturb and completely break up the connections of 
a bone so compactly and firmly seated as is the astragalus, and that, 
aside of any unusual complications, under the most favorable circum- 
stances, intense inflammation must naturally be anticipated ; and, with 
few exceptions, this has actually taken place. Even when reduction 
has been promptly and easily effected, inflammation, gangrene, and death 
have sometimes speedily ensued. But more often the reduction has been 
found to be exceedingly difficult or impossible, and complete removal of 
the bone or amputation has been immediately demanded. In a limited 
number of cases, on the other hand, the bone has been easily reduced, 
and recovery has taken place, with a tolerably useful limb ; or resection 
has been practised w T ith an equally favorable result ; in still other cases 
the bone has been left protruding, and the patient has finally recovered 
so far as to be able to walk again, but in such a crippled condition as to 
render the achievement a very doubtful triumph of conservative surgery. 

M. Poinsot has attempted to decide, by means of figures, in what proportions 
these very opposite results are to be hoped for or feared. " Out of seventy-eight 
cases of simple double dislocation collected by M. Broca, he finds that nineteen 
were reduced. M. Dubrueil, since the date of publication of Broca's statistics, 
counted five reductions out of twelve cases of double dislocation without any 
primary wound. Beginning in 1864, when Dubrueil's statistics were published, 
I have been able to collect thirty-one cases of simple double dislocation, in 
which attempts at reduction were made, and which furnished nineteen successes. 
Twenty-one of the latter cases were published elsewhere : in that number reduc- 
tion had been effected twelve times ; of the nine other patients, one had suffered 
immediate amputation, and the last eight had been submitted, at least at the 
beginning, to the expectant treatment/' According to Broca, the attempt at 
reduction failed in 54 cases out of 63. Poinsot narrates briefly other cases col- 
lected by himself, and which have been reported bv Gueniot,- Busch, 3 Iverson, 4 
Gore, 5 Uthoff, 6 Ward, 7 Fairbank, 8 Hird, 9 Landerer, io Lloyd, u and F. H. Hamil- 

1 Norris. George W.. Amer. Journ. Med. Sci., 1837, p. 383. 

2 Gueniot, Gaz. rtes Hop., 1872, No. 94. 

3 Busch (Madelung), Berliner klin. Wochen., 1873, 7 u. 8. 

4 Iverson, Xordiskt Med. Ark., 1876, Bd. viii. Hit. 3. 

5 Gore, The Lancet, 1880, vol. i. p. 625. 6 Uthoff, The Lancet, 1880, vol. i. p. 701. 

7 Ward. The Lancet, 1880, vol. i. 8 Fairbank, The Lancet, 1880, vol. i. p. 745. 

9 Hird, The Lancet, 1878, vol. i. p. 311. )0 Landerer, Centralb. fur Chir., 1881, p. 609. 
11 Llovd, The Lancet, 1882, vol. ii. p. 353. 



788 TARSAL DISLOCATIONS. 

ton. 1 "Out of the eleven preceding cases, therefore," says Poinsot, "reduction 
was successful eight times ; in the other three cases, extirpation of the astragalus 
had to be performed at a varying period following the accident. The three 
patients operated upon recovered in good condition. By adding our statistics 
to those of Broca and M. Dubrueil we reach a total of 121 cases of reduction, 
with 43 successes, making an average of successes of 35.5 per cent. I will call 
attention to the fact that our personal statistics, which are more recent than the 
two others, furnish an average of successes not below 61.2 per cent. 

" In the fortunate cases, three times (cases of Crosse, Bryant, Moore) the 
reduction could not be accomplished until after the tendo Achillis had been 
divided ; such was the case with Cock's patient, mentioned by Dubreuil. In 
two of the cases where reduction could not be effected, the surgeons (Busk, 
Cheevers) had not only divided the tendo Achillis, but also the tibialis posticus, 
the extensors of the toes, and the extensor proprius pollicis. Pichorel, of Havre, 
was not more successful, but he had only divided the tendo Achillis. Broca has 
reported four additional cases of tenotomy, taken from Chaussier, Despaulx, 
Solly, and from the clinic at Marseilles : reduction was only obtained twice. I 
will also state Shaw's case, recalled by Dubrueil, and in which the division of 
the tendon of the flexor longus did not effect the reduction. After all, tenotomy, 
practised in twelve cases, effected the reduction six times, thus giving an average 
of 50 per cent., which exceeds by 15.6 per cent, that furnished where attempts 
at simple reduction were made. With such results, one may be allowed to 
wonder why tenotomy is not resorted to more frequently in cases of irreducible 
dislocations. 

" It is especially in the dislocations backward that failures at reduction have 
been most frequent: in twenty cases which we have been able to collect, reduc- 
tion was effected only four times. The first one of those cases was reported by 
Malgaigne, without any author's name : the only indication as to its origin states 
that it was observed in 1839, in one of the hospitals of London ; the displace- 
ment, which had occurred inward and backward, was reduced in ten minutes, by 
means of strong extension combined with lateral pressure. Erichsen, although 
insisting upon the extreme difficulties that are met with in the dislocations back- 
ward, declares that the surgeons of the University Hospital of London recently 
succeeded in a case which was complicated with a fracture of both bones of the 
leg. Erichsen advises the subcutaneous section of the tendo Achillis in cases 
where the ordinary procedures have failed. The third case was published in 
detail by Dr. Blatin, of Clermont-Ferrand : A man 50 years of age, robust and 
muscular, falling into a cellar from a height of several feet, dislocated the 
astragalus directly backward : the displacement was incomplete as to its rela- 
tions with the articular ends of the tibia and fibula, complete as to its relations 
with the scaphoid and both articulations of the calcaneum. M. Blatin, in order 
to obtain the reduction, resorted to the following procedure : * I made vigorous 
traction upon the calcaneum, in order to disengage that bone from the groove 
of the astragalus and so as to obtain sufficient room for the return of the astrag- 
alus. Then I extended the foot strongly upon the leg, in such manner as to 
disengage the hollow of the articulation of the calcaneum with the astragalus, 
and so as to use the posterior and superior portion of the calcaneum as a means 
of pushing the astragalus forward. . . . After the second attempt, the astrag- 
alus had resumed its normal position.' Finally, in 1875, Dr. Morgan stated, at 
the Pathological Society of London, that he had recently seen a case of disloca- 
tion of the astragalus backward, without fracture, where the reduction was easily 
effected. 

" In eight cases out of fifteen, the results of which are known to us, failure at 
reduction did not deprive the limb of more or less usefulness. Lizars states that 
he saw a case of dislocation backward where, although all attempts at reduction 
had failed, the limb was saved, and afterward the patient could use it pretty 
well. Such was the result in a case in Mr. Liston's practice. Phillips has pub- 
lished two cases of dislocation backward which had resisted all efforts : the two 
patients walked easily, notwithstanding the persisting displacement ; one of 
them wore a shoe cut behind in order to avoid pressure upon the projecting 

1 Hamilton, 5th ed. of this treatise, 1880, p. 774. 



DISLOCATIONS OF THE ASTRAGALUS. 789 

astragalus. A patient of Cheevers, to whom I have already alluded when speak- 
ing of tendinous sections, recovered notwithstanding the gangrene of the skin 
on a level with the astragalus ; five months after, he walked pretty easily with 
a cane. In the two other cases, the dislocation had not been recognized in the 
beginning, and had been mistaken for a fracture ; one of them has been reported 
by the author of this treatise. 

" Dr. MacCormac, in 1875, presented to the Pathological Society of London a 
specimen of dislocation of the astragalus taken from a subject who had had the 
leg amputated for a chronic affection of the knee. The dislocation dated back 
two years, and had been treated for a fracture. The deformity was very slightly 
marked, and the patient walked easily with the aid of a cane. He could climb 
a ladder and walk on the scaffoldings. At the dissection, the head of the astrag- 
alus was found in place, but the body of the bone was displaced backward and 
adhered to the tendo Achillis ; the other tendons passed on the sides of the dis- 
located portion of the bone. At the same meeting, Dr. MacCormac recalled a 
similar fact of Mr. Legros Clark, which dated back to 1863 : the patient when 
seen again recently (1875), twelve years after, walked very well with his unre- 
duced dislocation. 

" But, in a certain number of cases, the expectant treatment resulted in gan- 
grene of the skin over the projecting astragalus, and extraction of the bone had 
to be resorted to. Such was the measure adopted in two cases by Foucher, 
Buchanan, and Williams, of Dublin. In each case the operation was followed 
by success. In a patient of M. Pichorel, of Havre, two attempts at reduction 
and section of the tendo Achillis were followed by a purulent arthritis which 
required amputation. Immediate extraction of the astragalus, in dislocations 
backward, has only been practised twice, by Hulme, of Dunedin, and by Turner; 
the latter case being a compound dislocation. In both cases, the results of the 
operation were sufficiently satisfactory. The expectant plan of treatment, which 
has been relatively fortunate in dislocations backward, has only been followed 
by deplorable results in other displacements of the astragalus. Out of seventeen 
cases, I count only two successes ; and out of the fifteen failures, there was one 
death by gangrene, nine consecutive extractions, and one amputation. 

"The two successes belong to Dupuytren and Dr. Barton, of Philadelphia. I 
take from M. Dubreuil the very brief history of the first one of these cases: 'In 
a simple and complete dislocation outward, observed by Dupuytren, the bone 
could not be replaced : there occurred a superficial eschar which did not com- 
municate with the articulation, and two months after the accident, the patient 
could use the limb very well.' 

<k In a patient of Dauve, suffering with a dislocation of the astragalus forward 
and outward, with rotation on its antero-posterior axis, the pressure upon the 
integuments produced gangrene, and the exposed astragalus became necrosed. 
The result is not known to us, but the case may already be considered as one of 
the failures by the expectant plan. Two patients of Guthrie, in whom a similar 
displacement could not be reduced, could not possibly use their feet. A soldier, 
seen by Sir Wm. Fergusson, and who had a dislocation of the astragalus dating 
several years back, could only walk with the aid of a cane, and applied only the 
tip of the foot to the ground. 

" Dr. Wilson, of Manchester, has reported a case of dislocation outward of 
two years' standing. The right foot turned strongly inward, it rested on the 
ground with its external border, the point d'appui being represented by the 
external borders of the calcaneum and of the fifth metatarsal bone. The patient 
could not use the foot. There existed at the external side of the dorsal aspect 
a voluminous projection ; the integuments, at that point, would get inflamed on 
the slightest fatigue, and had ulcerated on several occasions. Wilson amputated 
the leg, and the patient recovered. 

" The cases of secondary extraction have given one death, which occurred in 
the practice of Dr. Smith, of Leeds. A tall and robust gentleman dislocated the 
astragalus while jumping out of a carriage, on May 14, 1864. The skin sloughed, 
the bone became loose, and Mr. Smith extirpated it on the 14th of June. One 
month after, the patient died with eschars on the sacrum. The same surgeon 
scores three recoveries out of three operations which he performed, the patients 



790 TARSAL DISLOCATIONS. 

being able to use their limbs perfectly. An equally good result was obtained in 
the cases of Busk, Cruveilhier, Lallemand, Loewer, and Shillitoe. 

" The dangers of the expectant method [except perhaps in the backward dis- 
location — H.] and the almost absolute necessity of resorting subsequently to 
extraction of the astragalus, have suggested to a certain number of surgeons the 
immediate performance of that operation. Such was the procedure which I 
adopted in a case mentioned above, in the chapter on Fractures of the Astrag- 
alus ; I will recall the fact that the patient died after having undergone ampu- 
tation of the thigh ; the extirpation was incomplete, as I had left in place the 
head of the bone which had maintained its relations with the scaphoid." 1 

George W. Norris, of Philadelphia, relates the following case, illustrating the 
imminent danger to which even the life of the patient may be exposed in those 
examples which are apparently the most simple: W. S., set. 30, was admitted to 
the Pennsylvania Hospital on the 26th 'of September, 1831. An hour previous, 
while descending a ladder, he slipped and fell in such a manner as to throw the 
entire weight of his body upon the outer part of his left foot. The foot was 
turned inward, and nearly immovable; a slight depression existed immediately 
below the lower end of the tibia, and there was a hard rounded projection on 
the outer part of the foot, a little below and in front of the extremity of the 
fibula; the skin over this projection was not broken or excoriated, but reddened; 
there was no fracture of either bone of the leg. The symptoms rendered it plain 
that the astragalus was dislocated forward and outward. Dr. Barton, under 
whose care the patient was received, proceeded soon after to make attempts at 
reduction. The muscles of the leg were relaxed as much as possible, and exten- 
sion made from the foot by seizing the heel and front part of the foot while an 
assistant made counter-extension at the knee. The bone was also pushed inward 
toward the joint by the surgeon. These efforts were continued for a considerable 
time, but had no effect in changing the position of the bone. Six hours after- 
ward, Drs. Harris and Hewson being in consultation, the attempt was again 
made to accomplish the reduction, but without success; and the surgeons imme- 
diately proceeded to excise the bone. An incision was made parallel with the 
tendons, commencing a short distance above the projection, and extending down 
far enough to expose fairly the astragalus and its torn ligaments. The bone was 
then seized with the forceps and easily removed after the division of a few liga- 
mentous fibres that continued to connect it with the adjoining parts. Very little 
bleeding occurred, only two small arteries requiring the ligature. After removal, 
it was discovered that about one-half of the surface which plays in the lower end 
of the tibia had been fractured, and that it remained firmly attached to the 
extremity of that bone. No attempt was made to remove this fragment, but, the 
joint being carefully sponged out, the sides of the wound were brought together 
and closed by sutures, adhesive straps, and a roller; after which the foot, placed 
in its natural position, was laid in a fracture-box. On the fifth day a slough 
began to form upon the outside of the foot, which was followed by suppuration 
at other points, and on the thirteenth day an opening was made to evacuate the 
pus near the malleolus internus. At the end of about eight weeks the fragment 
of the astragalus which had been suffered to remain was found to be carious, 
and it was removed ; the heel also had ulcerated from pressure, and several other 
bones of the tarsus were discovered to be carious. Fifteen months later, this 
poor fellow was still in the hospital, suffering from hectic, with extensive disease 
in the bones of the tarsus and ankle-joint. Finally, amputation of the leg was 
practised by Dr. Barton, a few days after which the patient died. 2 

Norris mentions also two examples of simple dislocation of the astragalus at 
the Pennsylvania Hospital which came under the observation of Dr. Barton, in 
both of which the bone was left unreduced. In one case inflammation and 
sloughing soon effected a complete exposure of the protruding bone, but after a 
time the skin cicatrized. At the end of five months the patient walked and had 
good use of the joint, though great deformity of the foot existed, and he contin- 
ued to be subject to ulceration of the newly formed skin on its outer part. In 
the other case gangrene supervened soon after the accident, and the patient 

1 Poinsot, French ed. of this treatise, p. 1182 et seq. 

2 Norris, George W., Amer. Journ. Med. Sci., Aug. 1837, p. 378. 



DISLOCATIONS OF THE ASTRAGALUS. 791 

died. Norris adds that " the late Professor Wistar removed the astragalus in a 
case of compound dislocation, and the patient was cured with some motion at the 
joint." Dr. Alexander Stevens, of New York, made the same operation in a 
case of compound dislocation, and, after several months, he affirms that the 
patient " has recovered with very trifling deformity of the foot, and with a flex- 
ible joint. He walks with very slight lameness." 1 

I am indebted to Dr. B. H. Hart, of Marietta, Ohio, for an account of the 
following case, and for the. specimen : In June, 1853, T. W. was thrown from 
his carriage, alighting upon his left foot and causing a compound dislocation of 
the ankle-joint. Dr. Hart was immediately called, and found the bones of the 
leg thrust through the integuments on the outside, the malleolus interims broken, 
and the astragalus partially dislocated. After enlarging the opening in the 
integuments with a pocket-knife, the doctor was able to reduce the dislocated 
bones. It must be mentioned that this man weighed 225 pounds, and that in 
his fall he descended a precipice or bank thirty feet in height. Extensive sup- 
puration throughout the joint resulted, and some fragments of the bone came 
away ; and on the thirty-third day Dr. Hart removed, without the aid of the 
knife, the entire astragalus. In three months the patient walked upon crutches, 
and in eleven months he could walk well without a staff, a slight motion having 
been preserved in the ankle-joint. 

The dislocations backward, of which we have found recorded only 
twenty examples, have all, with but four exceptions, been left unreduced; 
yet in several instances the patients have recovered with pretty useful 
limbs. Such was the fact with Liston's, Lizars', and my own patients, 
and also with Mr. Phillips's two cases, to all of which I shall again refer. 
It must be noticed, however, that, in each of the cases mentioned as 
followed by a successful termination without reduction, the dislocations 
were simple. 

Turner, of Manchester, has reported one example of compound dislocation 
outward and backward, in which, finding himself unable to effect reduction, he 
removed the astragalus, with a tolerably successful result. 2 Finally, a case was 
presented in one of the London hospitals in 1839, of a dislocation inward and 
backward, which was reduced in about ten minutes, by extension accompanied 
with lateral pressure. 3 

In September, 1870, I saw, with Dr. Sayre, in consultation, a subluxation of 
the astragalus forward and outward, in the person of Mr. Stewart, of this city, 
which had just occurred in consequence of an injury received in being thrown 
from a carriage. The dislocation seemed to be nearly but not quite complete, 
causing great projection and tension of the skin. Under the influence of chloro- 
form, by extension and pressure, it was easily reduced by Dr. Sayre. In five 
weeks from this time he was able to walk, and soon after the restoration of the 
functions of the joint was complete. 

Basil Norris, Surgeon U. S. A., in a paper read before the American Surgical 
Association in 1883, reports a case of dislocation of the astragalus forward and 
outward, caused by being thrown from a carriage, and alighting upon his foot. In 
less than an hour after the accident, under the influence of ether, it w T as reduced 
by Drs. Lincoln and Ashford, of Washington. The method employed was to 
draw the foot forcibly downward, while it was at the same time rotated outward. 
The first attempt was unsuccessful ; but in the second, the extension being aided 
by direct pressure, the bone was at first partially restored to its position ; the 
restoration being finally completed by continued extension, and by direct pres- 
sure upon the neck of the astragalus. No grave inflammatory accident ensued. 
The same paper contains communications from several surgeons reporting similar 

1 Stevens, North Amer. Med. and Surg. Journ,, Jan. 1827, p. 200. 

2 Turner, Trans. Provin. Med. and Surg. Journ., vol. ix. Essay on Dislocations of Astrag- 
alus, with nearly fifty cases. For additional cases, see Med. and Surg. Eeporter, Jan. 1867. 

3 London Lancet, vol. ii. p. 559. 



792 TARSAL DISLOCATIONS. 

cases ; only one of which, that of Dr. John Brinton, of Philadelphia, 1 had been 
previously reported. 

In Dr. Brinton's case the astragalus was dislocated forward and inward, and 
the fibula was broken, but the integuments were not torn. Several ineffectual 
attempts at reduction were made on the same day by Drs. Brinton and Moss. 
A severe inflammation ensued, with other alarming symptoms, and on the four- 
teenth day Dr. Brinton practised excision. A portion of the os calcis subse- 
quently became carious, and was removed, and he finally recovered with a 
tolerably useful limb. 

A communication from Dr. J. W.'S. Gouley, contained in the same paper, 
gives an account of a case of simple dislocation forward and outward which he 
had reduced, Reference is made also to other cases seen by Drs. Gouley, 
Vollum, and Agnew, but not with sufficient precision to render their repetition 
in this place useful. 

Treatment. — Various attempts have been made by surgical writers to 
determine the line of treatment which should be adopted in these un- 
fortunate cases, but with very unsatisfactory results, since they are far 
from having arrived at similar conclusions, nor have they been able 
always to settle the question definitely for themselves. The difficulty 
consists in the multiplicity and lack of uniformity in the complications 
which attend these accidents, rendering it impossible to establish a classi- 
fication upon which a uniform treatment may be safely based. There 
are certain principles, however, which seem to be sufficiently settled to 
allow of an authoritative announcement ; these may be briefly stated as 
follow r s : If the dislocation is simple, reduce the astragalus immediately, 
provided this is possible. If the dislocation is complete, and it cannot be 
reduced, even partially, except in cases of dislocation backward, proceed 
at once to resection or to amputation. In compound dislocations, resec- 
tion or amputation affords the only safe resource. In all cases the in- 
flammation is likely to be intense, in order to prevent which complication 
the surgeon must be unremitting in his use of the appropriate remedies. 

The several indications and rules of treatment above enumerated I 
shall proceed to illustrate a little more fully. In a recent simple dislo- 
cation of the astragalus forward, the leg should be flexed to a right angle 
with the thigh, and, for the purpose of making extension, one assistant 
should take hold of the foot in both hands in the same manner that a 
servant draws a boot — that is, with the right hand grasping the heel, and 
the left placed upon the dorsum of the foot, near the toes. A second 
assistant should seize the lower part of the thigh, in order to make coun- 
ter-extension, while the surgeon presses with the ball of his hand against 
the head of the astragalus, upward and backward. If these simple meas- 
ures fail, the pulleys ought to be employed as a substitute for the hands 
in making extension. In applying the extension, the toes must be kept 
well down, and occasionally the foot should be moved gently from one 
side to the other. 

An oblique dislocation must be reduced, if possible, to an anterior 
dislocation, before an attempt is made to carry the head of the bone back 
to its place, as by this mode the reduction will be greatly facilitated. 

Lateral dislocations may be reduced by the same means ; but if the 
astragalus is dislocated outward, the foot must be held forcibly adducted 

1 Brinton, Photographic Rev., No. 2, Dec. 1870. 



DISLOCATIONS OF THE ASTRAGALUS, 



793 



during the extension ; and if it is dislocated inward, the foot may be held ' 
strongly in the opposite direction. 

Lizars says that he has seen one case of backward dislocation, and that all 
attempts at reduction were unavailing. The limb was, however, preserved, and 
proved to be useful. 1 Liston was equally unsuccessful in a case which came 
under his notice. 2 Phillips has reported two cases, in neither of which was the 
reduction accomplished. 3 Nelaton has seen a compound dislocation which he 
could not reduce. 4 Mr. Erichsen, however, who believed that when dislocated 
backward it had not hitherto been reduced, declares that the surgeons at Uni- 
versity Hospital have succeeded in one case recently, in which both the tibia 
and fibula were broken also. 5 Mr. Erichsen suggests also that, in case of a fail- 
ure by the ordinary means, we should resort to a subcutaneous section of the 
tendo Achillis. Mr. Williams, of Dublin, in a similar case, which had been left 
unreduced, was obliged finally to extract the bone, in consequence of the integu- 
ments having sloughed. 6 

In February, 1875, Mr. J. N. Hall, of Colorado, set. 38, consulted me in refer- 
ence to an injury to his foot sustained two years before. The foot had been 
caught between a couple of timbers and violently twisted inward. The nature 
of the accident was not at first recognized. I found the astragalus displaced 
backward as far as the posterior extremity of the calcaneum, causing the tendo- 
Achillis to curve backward ; the astragalus was especially prominent on the 
inner side, posteriorly. The foot was at a right angle with the leg, and short- 
ened in front three-eighths of an inch. The leg was shortened five-eighths of an 
inch. The foot was at times painful and numb. He walked very well with the 
aid of a cane. Of course, no surgical interference could be recommended. 

Compound dislocations, and such as are otherwise complicated, demand 
of the surgeon immediate amputation or exsection, the latter of which 
ought to be preferred whenever the condition of the limb encourages a 
reasonable hope that the foot may be saved. 

Dr. Grant, of Canada, has reported a case of success after reduction of a com- 
pound dislocation of this bone. The man was 35 years old, and in good health. 
Immediately after the accident the astragalus was found completely dislocated 
forward, and lying with its long axis placed transversely, so that the anterior 
extremity protruded through the integuments one inch on the outer side of the 
foot. There was no fracture. The first attempt at reduction, by extension and 
pressure failed ; but in the second attempt moderate pressure, without exten- 
sion, was successful. Suppuration ensued, and continued two months. At the 
end of eight months he walked without a cane ; and at the date of the report the 
ankle was in all respects perfect. 7 

"In the dislocation by rotation, or renversement," says M. E. Delorme, 
"if the bone has been rotated upon its antero-posterior axis to the extent 
of 90 degrees, thus having brought its trochlear surface inward or out- 
ward, it is necessary, in order to effect reduction, that while pulling on 
the foot, the bone should be tilted, outward in inward dislocation, and 
inward in the external variety, which is done by pressing upon the margin 
of the facet which has become superior. In a case of dislocation by ren- 
versement, the surgeon must try first, by a tilting motion, to convert that 



1 Lizars, System of Practical Surg., Edinburgh ed., 1847, p. 161. 

2 Liston, Elements of (surgery, vol. iii. p. 348. 

3 Phillips, Lond. Med. Gaz., vol. xiv. p. 596. 

4 ISTelaton, Pathologie Chirurg., t. ii. p. 482. 

5 Erichsen, Science and Art. of Surg., Amer. ed., 1859, p. 270. 

6 Williams, Erichsen, op. cit., p 271. 

7 Grant, Canada Med. Journ., Oct. 1866. 



794 TARSAL DISLOCATION'S. 

rotation of 180 degrees into one of 90 ; and then to press again upon one 
of the margins of the bone, in order to transform the displacement into 
an ordinary dislocation inward or outward." 

When exsection is practised, and the bone is found to be broken, as it 
often is, all the fragments should be carefully removed, since they are 
certain to become necrosed if left in place. Nor ought the surgeon to 
hesitate to lay open freely the tissues in every direction, in order that he 
may accomplish this purpose ; even the tendons lying over the protrud- 
ing bone may be sacrificed unhesitatingly, since, after having been so 
severely bruised, stretched,, and lacerated, they are pretty certain to 
slough. Indeed, the more freely the tissues are divided over the bone, 
the less will be the danger of inflammation, and the safer will be the life 
and limb of the patient. 

The following case, reported by Dr. W. A. Gillespie, of Ellisville, Va., will 
illustrate the occasional value of exsection in compound dislocations: Mrs. A., 
aged about 50 years, fell from a horse on the 23d of May, 1833, dislocating both 
ankles. The dislocation of the right foot was accompanied with a dislocation 
of the astragalus outward, which projected through a very large wound in the 
integuments, and its trochlea was placed at an angle of about 45° with its nat- 
ural position. Early on the following day it was removed by severing its few 
remaining connections, and the wound was immediately closed by stitches, adhe- 
sive plasters, and light dressings. From the moment of the receipt of the injury, 
and for several days afterward, she suffered excruciating pain in the limb, and 
on the third day tetanus was apprehended, but its full accession was prevented 
by the free use of opiates. The limb was suspended in N. R. Smith's fracture- 
apparatus ; and as gangrene with hectic fever soon threatened the life of the 
patient, fermenting poultices were diligently applied, and the patient was sus- 
tained by wine, bark, and other tonics. Two months after the injury was 
received, the date at which the report is given, the wound had entirely healed, 
and her complete recovery was regarded as certain. 1 

§ 2. Astragalo-calcaneo-scaphoid Dislocations. 

It is perhaps quite as common for the astragalus to be dislocated from 
the scaphoid bone and calcaneum, while it retains its connections with 
the tibia, as to be dislocated from all these bones at the same time. This 
astragalo-calcaneo-scaphoid dislocation is that which Malgaigne has 
termed "subastragaloid." Produced by the same causes which deter- 
mine true dislocations of the astragalus, it may occur in the same direc- 
tions, and is liable to the same complications ; nor will either the prognosis 
or treatment differ essentially from that which is recognized and estab- 
lished in the other accident. 

As in dislocations proper of the astragalus, so also in this accident, opposite 
results have occasionally followed from similar modes of treatment. Dr. Det- 
mold, of New York, stated in 1856 to the New York Academy of Medicine, that 
he had recently met with a dislocation of the astragalus in which the bone had 
retained its proper relations with the tibia, but not with the bones of the tarsus. 
The patient had fallen from a wagon and caught his foot in the wheel. Dr. 
Detmold made extension with pulleys, but could not effect the reduction. Sub- 
sequently he was obliged to remove the astragalus on account of the suppuration 
which followed and the consequent exposure of the bone. The wound did not 

1 Gillespie, Amer. Journ. Med. Sci., Aug. 1833, p. 552. 






DISLOCATIONS OF THE CALCANEUS. 795 

heal kindly, and at length amputation of the leg became necessary. Dr. Det- 
mold concludes, from this example and others which have come to his knowledge, 
that if a similar case were to present itself to him again, he would amputate at 
once. 1 

The following case, reported by Dr. Thomas Wells, of Columbia, S. C, is of 
unusual interest, as illustrating the danger of leaving the bone displaced, and 
also the benefit which may, even under the most unfavorable circumstances, result 
from its final removal : Dr. S., aet. 30, was riding in an open carriage, some time 
during the year 1819, when his horses became frightened and ran, and in leap- 
ing from his vehicle he struck upon his left foot, dislocating the astragalus from 
its junction with the scaphoid bone, upward and slightly outward. Several 
medical gentlemen made violent efforts to reduce the bone, but without effect. 
Inflammation and suppuration, accompanied by a high fever, soon followed, 
and the head of the astragalus, becoming carious, protruded through the skin. 
On the 18th of August, about seven months after the injury was received, he 
was still suffering from a copious discharge, pain, swelling, and general irritative 
fever, and it was determined to excise the bone, which was accordingly done by 
enlarging the wound and detaching its loose connections with the adjacent tis- 
sues. The astragalus extracted left a frightful wound, the foot seeming to be 
nearly separated from the leg. A hollow splint was adjusted to the inside of 
the foot and leg, so as to preserve the limb perfectly steady and in a proper 
direction ; simple dressings were applied, and an anodyne administered inter- 
nally. Xo accidents followed, and at the end of September the wound was 
healed, and the swelling of the parts had entirely subsided. One year after the 
operation he walked without the least difficulty, the ankle being then perfectly 
sound. The leg was shortened about one inch, and this deficiency was supplied 
by a thick heel upon his shoe. 2 

Examples might be cited illustrative of the value of early exsection where 
reduction could not be accomplished ; but, after what has already been said 
upon the subject of dislocations of the astragalus, I shall not regard any farther 
reference as either necessary or useful. 

If other principles of treatment are to govern the surgeon than those 
which I have already laid down they cannot here be stated. They are 
among those unwritten rules whose existence we cannot always recognize 
until the case arises to which they may apply. Yet, in the exigency 
supposed, they are as clearly defined, and as imperative, in the mind of 
the clever surgeon, as any of those laws which have been made the sub- 
jects of special record. 

§ 3. Dislocations of the Calcaneum. 

The calcaneum may, as a consequence of a fall upon the heel or of a 
direct blow, be dislocated outward from the astragalus alone or upward 
and outward from the cuboid bone at the same time. It has been found, 
also, according to Canton, at the same moment dislocated outward from 
the astragalus and inward upon the cuboid bone. 

Chelius says he has seen an old dislocation of the calcaneum, produced in 
early life by pulling off a boot, from which there finally resulted a degeneration 
like elephantiasis of the leg, rendering amputation necessary. 3 

Of the two cases of dislocation outward of this bone mentioned by Sir Astley 
Cooper, the first, that of Martin Bentley, was occasioned by the falling of a 
heavy stone upon his foot; the integuments were not broken, and the position 

1 Detmold, New York Journ. Med.. Mar, 1856, p. 383. 

2 Wells, Amer. Journ. Med. Sei., May, 1832, p. 21. 

3 Chelius, System of Surg., Amer. ed*., vol. ii. p. 354. 



796 TARSAL DISLOCATIONS. 

of the foot resembled a varus. "The dislocation was easily reduced, having 
bent the thigh and knee on the body and fixed the leg, by laying hold of the 
metatarsus and of the tuberosity of the heel-bone, and drawing the foot gently 
and directly from the leg, during which extension Cline put his knee against 
the outside of the joint, and the foot being pressed against it, the heel and the 
navicular bone readily slipped into their place, and the deformity disappeared." 
He was discharged from the hospital in five weeks, " having the complete use 
of his foot," In the second case, the dislocation, produced also by the fall of a 
stone upon the foot, was compound, and the patient, Thomas G., having been 
brought into St. Thomas's Hospital, the reduction was effected by extending 
the foot and rotating it outward. Six months after, when he left the hospital 
he was able to walk pretty well with a stick. 

A. Dumas 1 relates an example of this dislocation outward caused by a piece 
of wood falling upon the internal side of the ieg and foot. Jourdan, of Mar- 
seilles, in whose service the case was presented, reduced it easily by extension 
downward and outward combined with direct pressure. In another case reported 
by Dumas a man had been struck upon the posterior and external part of the 
heel and imprisoned by an anchor, in which condition of the limb the body was 
thrown to the left, Jourdan reduced the dislocation easily, as in the preceding 
case. At the end of a month the cure was complete. Dr. Edwin Canton 2 found 
in the dissecting-room of the Charing-Cross Hospital what he regarded as a 
traumatic dislocation outward upon the astragalus and inward upon the cuboid. 
Malgaigne and Poinsot have accepted Canton's view of the case, but Polaillon 
could interpret it only as a pathological displacement. Hancock 3 describes a 
specimen taken from an old man who had received his injury two years before 
death, causing a dislocation outward, which had not been reduced. Dissection 
showed that the calcaneum was slightly separated from the cuboid and more 
extensively from the astragalus, whose position in the articulation was com- 
pletely changed. The astragalus, tibia, fibula, and calcaneum were ankylosed 
by bony callus. 

§ 4. Middle Tarsal Dislocations. 

The scaphoid and cuboid bones may be dislocated from the astragalus 
and calcaneum, constituting what is termed, by Malgaigne, a "middle 
tarsal" dislocation. It is probable that, to some extent, the same thing 
has occurred in many of those cases which are reported as simple dislo- 
cations of the astragalus or as dislocations at the astragalo-scaphoid 
articulation ; but it occurs also occasionally in a degree so perfect and 
complete as to leave no cloubt as to the true nature of the disjunction, 
and to entitle it to a separate consideration. 

Mr. Liston mentions the case of a boy, set. 14, who fell from a height of forty 
feet, striking, apparently, upon the extremity of the foot. The scaphoid and 
cuboid bones were found displaced upward and forward, so that the foot was 
shortened about half an inch and had a clubbed appearance. No attempt was 
made to reduce the bones, and he left the hospital in three weeks, able to stand 
on the foot. 4 

Sir Astley Cooper has recorded in more detail a similar example : A man 
received upon the top of his foot a stone of great weight. He was immediately 
carried to Guy's Hospital, and his condition is described as follows: "The os 
calcis and the astragalus remained in their natural situations, but the forepart 
of the foot was turned inward upon the bones. When examined by the students, 
the appearance was so precisely like that of a club-foot that they could not at 

1 A. Dumas, Bull. Therap., 1854, t. xlvi. p. 550. 

2 E. Canton, The Lancet, 1847, vol. i. p. 506. 

3 Hancock, Anat. and Surg. Human Foot, London, 1873, p. 216. 

4 Practical Surgery; also London Lancet, vol. xxxvii. p. 133. 



DISLOCATIONS OF THE SCAPHOID BONE. 797 

first believe but that it was a natural defect of that kind;" but, upon the assur- 
ance of the man that previous to the accident his foot was not distorted, exten- 
sion was made, and the reduction was effected. He was discharged from the 
hospital in five weeks, having the complete use of his foot. 1 

E. Delorme 2 mentions two cases observed by Thomas and Anger, respectively. 
In Thomas's case the foot had been traversed by the wheel of a wagon. Reduc- 
tion could not be effected, and the patient died. The autopsy disclosed a dis- 
placement upward of the astragalus and calcaneum upon the second row of the 
tarsal bones. The scaphoid was broken, and one of its fragments protruded at 
the sole of the foot. The cuboid was only partially dislocated from the calca- 
neum. In Anger's case a man had fallen from a height, and the arch of the 
foot appeared a little flattened, but the displacement of the bones could not be 
made out. The patient having died of erysipelas, the autopsy revealed a com- 
plete dislocation of the astragalus and calcaneum forward upon the second row 
of the tarsal bones. The tubercle at the anterior portion of the scaphoid was 
almost completely torn away. Even after dissection it was found difficult to 
reduce the bones. 

§ 5. Dislocations of the Cuboid Bone. 

According to Piedagnel, quoted by Chelius, the cuboid bone may be 
dislocated upward, inward, and downward, but Malgaigne affirms that 
he has found no case recorded in which the dislocation has occurred 
alone, or unaccompanied with a dislocation of one or more of the other 
tarsal bones. 

§ 6. Dislocations of the Scaphoid Bone. 

Several examples are recorded of a true dislocation of the os scaphoides, 
in which the bone had abandoned both the astragalus on the one hand, 
and the cuneiform bones on the other. 

Burnett has seen a dislocation of the scaphoid bone in which its connections 
with the astragalus were undisturbed, while at the same time it was completely 
separated from the cuneiform bones. By strong pressure exercised during sev- 
eral minutes, the os scaphoides was made to fall into its place. The dislocation 
was compound, yet the wound healed rapidly, and in a short time the recovery 
was almost complete. 3 

Rizzoli 4 also reports an example of simultaneous dislocation of the astragalus 
and scaphoid in a direction "inward, upward, and forward," the injury being 
caused by jumping from a carriage. Rizzoli succeeded in effecting reduction 
with the aid of three assistants, by making counter-extension from the knee, the 
leg being in a position of semiflexion, while direct pressure was made upon the 
projecting scaphoid ; Rizzoli himself seized the toes and the heel with his two 
hands, and made traction, bringing at the same moment the foot upward. 

Garland, 5 of Liverpool, saw a child, aet. 4, with a compound dislocation of the 
scaphoid forward, caused by a direct blow upon the top of the foot. The sca- 
phoid was completely separated from the cuneiform bones. The reduction was 
effected not without much difficulty. When the child left the hospital there 
still remained some deformity, the foot being a little turned outward ; and the 
arch of the tarsus being somewhat flattened. 

Piedagnel mentions a case in which the scaphoid bone was broken longitudinally, 
and its internal fragment, constituting the largest portion, was displaced inward 

1 Sir A. Cooper on Disloc, etc., London ed , 1823, p. 376. 

2 Delorme, Thomas, and Anger. Poinsot, op. cit., p. 1210. 

3 Burnett, Lond. Med. Gazette, 1837, vol. xix. p. 221. 

4 Eizzoli, Clin. Chir. trad par Andreini, Paris, 1872, p. 14fi. 

5 Garland, Anat and Surg, of Human Food, London, 1873, p. 234. 



798 TAKSAL DISLOCATION'S. . 

through a tegumentary wound. He was unable to effect reduction, and was com- 
pelled to amputate the foot. 1 

Walker has reported an example of dislocation forward, occasioned by jump- 
ing upon the ball of the foot. The bone formed a marked projection upon the 
top of the foot, and a corresponding depression existed below. An attempt was 
first made to accomplish the reduction by simple pressure with the thumbs ; but 
this having failed, the surgeon bent the extremity of the foot forcibly downward, 
and continuing to press upon the scaphoid, it fell into its position easily and 
with a distinct click. In about three weeks the patient was able to walk with 
only a slight halt, and no deformity remained. 2 

Robert W. Smith 3 has also reported a case of ancient dislocation of the scaphoid 
upward, in a man who several years before had fallen from a horse, the foot 
being caught in the stirrup under the animal. The bone projected in front of 
the head of the astragalus : the sole of the foot was very much flattened, but 
walking was not at all interfered with. 

§ 7, Dislocations of the Cuneiform Bones. 

The cuneiform bones may be dislocated without having separated from 
each other, of which two or three examples are recorded, or, which is 
more common, the internal cuneiform may be dislocated alone. Sir 
Astley Cooper has twice seen this bone dislocated : once in a gentleman 
who called upon him some weeks after the accident, and a second time 
in a case which occurred in Guy's Hospital. In both instances the same 
appearances presented themselves. There was a great projection of the 
bone inward, and some degree of elevation, from its being drawn up by 
the action of the tibialis anticus muscle ; and it no longer remained in a 
direct line with the metatarsal bone of the great toe. In neither case 
was the bone reduced. The subject of the first of these accidents walked 
with but little halting, and he believed would in time recover the use of 
the foot, so as not to appear lame. The cause of the accident was a fall 
from a considerable height, by which the ligament was ruptured which 
connects this bone with the os cuneiform, and with the os naviculare. 
The second case, which was in Guy's Hospital, happened by the fall of 
a horse, and the foot was caught between the horse and the curbstone. 4 

Villars 5 met with an example of dislocation of the cuneiform internum upward 
and inward, which he reduced by extension, abduction, and pressure on the 
second day ; at the end of two months the patient could walk easily. In a case 
reported by Meynier 6 the dislocation of this bone was thought to be due to 
muscular contraction alone. The reduction was easily effected. Fitz-Gibbon 7 
reports a case of dislocation of the internal cuneiform downward and inward, 
from a direct blow. Reduction was easily accomplished by extension and direct 
pressure, and recovery took place without accident. Lemoine 8 met with a sim- 
ilar case in which reduction attempted on the nineteenth day was found impos- 
sible. Four months after the accident the patient was able to walk, but not 
without fatigue. In a case of compound dislocation seen by Mr. Key, reduction 
was effected, and in two months the cure was so far completed that the patient 

1 Piedagnel, Journ. Univ. et Heb , torn. ii. p. 208. 

2 Walker, The Medical Examiner, 1851,. p. 203. 

3 R. W. Smith, Dublin Hosp. Gaz., 1855, vol. ii. p. 76. 
* Sir Astley Cooper, op. cit., p. 383. 

5 Villars, Poulet, Gaz. Med. de Paris, 1851, p. 757. 

6 Meynier, Gaz. Med. de Paris, 1851, p. 520. 

7 Fitz-Gibbon, Dublin Journ. Med. Sci., 1877, vol. lxiv. p. 271. 

8 Lemoine. Rev. Mens, de Chir ,1883. No. 2, 121. 



DISLOCATIONS OF THE CUNEIFORM BONES. 799 

walked with only a slight lameness. 1 Nelaton, in a similar case of compound 
dislocation, unable to reduce the bone, removed it completely, and the patient 
recovered. 2 

A dislocation of the sound cuneiform has been observed by Wm. H. Folker 3 
and by B. Anger. 4 In Folker's case reduction was easily effected. In the case 
reported by Anger the dislocation was incomplete, not protruding more than one 
centimetre, but it could not be reduced. 

Robert Smith has called attention to a species of dislocation of the 
internal cuneiform bone not before very accurately described ; but of 
which he has presented two examples. It consists in simultaneous dis- 
location of the metatarsal and internal cuneiform — that is to say, the 
first metatarsal bone, together with the internal cuneiform, is dislocated 
upward and backward upon the tarsus, carrying with it also the four 
remaining metatarsal bones. In both of the examples seen and recorded 
by him the dislocations were ancient, and no account could be obtained 
of the precise manner in which the accidents had been produced. The 
feet were foreshortened to the extent of an inch or more in consequence 
of the overlapping of the bones, yet the heel in each case preserved its 
natural relations to the tibia, not being proportionally lengthened as 
is the case in dislocations of the tibia forward. The plantar surface of 
the foot was turned inward, and instead of being concave it was convex, 
both in its antero-posterior and transverse diameters. A transverse ridge 
on the top of the foot also indicated the line of the projecting bones. 
Both of these cases were verified by a careful dissection. 5 

Dupuytren has reported a similar case, occurring in a woman, set. 39, who 
was brought immediately to Hotel Dieu. She stated that in descending from 
the bridge of St. Michael, with a burden of two hundred pounds, she fell in such 
a way that the whole weight of the body was received on the right foot, and that, 
at the moment she made an effort to check herself in falling, she experienced 
severe pain in this part, and heard a very distinct snap ; she was unable to raise 
herself from the ground. On the following morning Dupuytren reduced the 
bones with very little difficulty by extension, combined with pressure against the 
dislocated ends. The bones went into place with a loud snap, and in two or 
three months she left the hospital, with only a little lameness. 6 Bryant has 
seen two cases of simultaneous displacement of the cuneiform internum and the 
corresponding metatarsal bone. 

Mr. Smith, without intending to question the possibility of a simple 
dislocation of the metatarsal bones, of which, indeed, Malgaigne has col- 
lected a number of well-authenticated examples, is inclined to believe 
that, when a dislocation of the bones of the metatarsus is the consequence 
of a fall from a height, the individual alighting upon the anterior part of 
the foot, it is, in general, that variety which has now been described. 
And this aptness on the part of the cuneiform bone to maintain its con- 
nection with the first metatarsal bone, he would ascribe mainly to the 
fact that both the peroneus longus and tibialis anticus have attachments 
to each of the bones in question. 

1 Key, Guy's Hosp. Rep., 1836, vol. i. p. 544. 

2 Nelaton, Malgaigne, op. cit., p. 1076. 

3 Folker, The Lancet, 1856, vol. ii. p. 283. 

4 A. Anger, Traite iconographique des Malad. Chir., Paris, 1865, p. 356. 

5 Robert Smith, Treatise on Fractures, etc., Dublin ed., 1854, p. 224 et seq. 

6 Dupuytren, op. cit., p. 326. 



800 DISLOCATIONS OF THE METATARSAL BONES. 

Dr. Bertherand, of Algiers, 1 in 1856 reported a case of simultaneous disloca- 
tion of all the cuneiform bones, without separation from the metatarsal bones, 
caused by a fall upon the sole of the foot. The dislocation was not reduced, and 
was only seen by Bertherand two years after the accident occurred. The foot 
was atrophied ; the tarsal and metatarsal articulations were ankylosed, and he 
walked entirely on his heel. 



CHAP TEE XX I Y. 

DISLOCATIONS OF THE METATARSAL BONES. 

Dislocations of one or more of the metatarsal bones, at the points of 
their articulations with the tarsus, have been known to occur in almost 
every direction. They may be occasioned by crushing accidents, or 
more often perhaps they have been caused by a fall backward or forward, 
when the anterior extremity of the foot was wedged under some solid 
body and immovably fixed. They may be produced, also, by alighting 
upon the ball of the foot when falling from a height. 

Mr. Robert Smith inclines to the opinion that this will, in general, only pro- 
duce the species of dislocation which he has particularly described, and to 
which reference has been made in the preceding chapter. 

The symptoms which characterize the dislocation of the whole, range of 
metatarsal bones upward and backward will , when the dislocation is com- 
plete, resemble very much those which belong to the dislocation described 
by Smith. The dorsum of the foot will be shortened antero-posteriorly, 
the two arches of the foot will be lost upon the plantar surface, or even 
actually reversed, a ridge will traverse the back of the foot and a corre- 
sponding depression will exist underneath. In some cases, however, the 
dislocation is not complete, the articulations being only sprung, and then 
there can exist no foreshortening of the foot, and all the other signs will 
be less striking. 

The diagnosis is generally very easily made out, if only a single bone 
is dislocated, unless, indeed, considerable swelling has already occurred. 

Treatment. — The cases cited illustrate the difficulty which surgeons 
have experienced in the reduction of these bones, when a portion only is 
displaced : a difficulty which is probably due to the fact that it is almost 
impossible to make extension upon a single metatarsal bone. We might 
expect more from forced dorsal flexion, as advised in the case of the 
phalanges, and which was successfully practised by Shaw. Direct pres- 
sure upon the displaced head cannot be expected to accomplish much in 
these accidents, owing to the small amount of surface presented against 
which the force can be properly applied. If, on the other hand, all the 
bones are dislocated at once, the reduction is generally accomplished with 
ease by simple extension, combined w T ith properly-directed pressure. 

1 Bertherand, Bull. Soc. de Chir. de Paris, 1856-57, t. 7, p. 361. 



DISLOCATIONS OF THE METATARSAL BONES. 801 

Bouchard and Meynier succeeded without difficulty in two cases of backward 
dislocation; Smyley was equally successful on the sixth day, in a case of dislo- 
cation downward. Laugier reduced an outward dislocation of all the bones by 
pressure and extension easily ; and Kirk succeeded as well, in an example of 
the opposite character, ail the bones being carried inward. 1 

Mr. Sandwith has given us an account of a case which occurred in his own 
person, from the fall of his horse upon his foot. " I was instantly sensible,'' 
says Mr. Sandwith, " of the nature of the injury, and as soon as I was upon my 
feet, the metatarsus was found to be drawn upward, and obliquely outward upon 
the tarsus, by the action of the flexor muscles. On the removal of the boot, 
which was cut away, these were the appearances : The foot considerably short- 
ened, the toes turned a little outward, and a hard swelling, bigger than an egg, 
upon the tarsus, with tumefaction of the integuments. The pain, which was 
great at first, was kept under by a warm fomentation. The reduction was easily 
effected by my friends Messrs. Williams and Brereton, and leeches and bread- 
and-water poultices prevented inflammation. For several nights the foot was 
violently shaken by spasmodic action of the muscles, but the parts preserved 
their relative situation; and although it was nearly a year before all lameness 
ceased, yet at the end of six weeks I was enabled to lav aside my crutches. For 
the ability to use the foot in so short a time, I was indebted to a contrivance 
which rendered the foot and ankle inflexible. Instead of an elastic sole to the 
shoe part of the apparatus, one of wood was procured, around the heel of which 
was nailed a piece of firm, unbending leather ; this reached as high as the calf 
of the leg; three small straps with buckles held the leg in situ, and a broader 
one across the instep secured the foot. The comfort I experienced from this 
simple apparatus is my reason for describing it so particularly ; it has since been 
found useful in various injuries of the foot and ankle.'" 2 

In one extraordinary case, however, Dupuytren was not so successful. P. E., 
set. 24, fell, while drunk, into a ditch six feet deep, and alighted on the soles of 
his feet. The accident was followed by great swelling, and he did not suspect 
the nature of the injury, nor present himself at the hospital until three weeks 
after. Dupuytren then ascertained that he had dislocated the metatarsal bones 
of both feet. Several fruitless attempts were made to accomplish the reduction, 
but to no purpose, and in about two weeks he left the hospital. 3 

Mr. South says that, in 1835, a case was admitted to St. Thomas's Hospital, 
under Mr. Green's care, of dislocation of the last two metatarsal bones, occa- 
sioned by the falling of a heavy chest upon the inside of the foot. " Upon the 
top of the foot was a large swelling before and below the outer ankle, and behind 
it a cavity in which two fingers could be easily buried, in consequence of the 
bases of the metatarsal bones having been thrown upward and backward upon 
the top of the cuboid." The reduction was accomplished with much difficulty 
by continued extension, and as the bones resumed their places a distinct crack- 
ling was heard. 4 

Liston reduced a dislocation upward of the first metatarsal bone. Malgaigne 
mistook a dislocation of the fourth bone for a fracture, and did not attempt the 
reduction until the seventh day, when after five successive trials, the head 
entered with a noise into its cavity. In a dislocation of the second, third, and 
fourth metatarsal bones, he also failed to detect the true nature of the accident 
until the tenth day, when he proceeded to attempt reduction, but failed. In- 
flammation, suppuration, and delirium followed, and the patient died on the 
forty-first day. Tufnell failed in a similar case, although his patient finally 
recovered with a not very useful limb. Malgaigne failed to reduce the bones 
also in a recent case of dislocation of the first four bones, although he used 
chloroform and diligently tried various means. The same writer has seen'one 
example of ancient dislocation, which was not recognized by the surgeon by 
whom the patient was first seen. Monteggia reports a case of dislocation of the 

1 Malgaigne, op. cit., p. 1081. 

2 Sandwith, Araer. Journ. Med. Sci., Nov. 1828, p. 216; from London Med. Gaz., vol. i. 

3 Dupuytren, op. cit., p. 329. 

4 South, Note to Chelius, vol. ii. p. 256. 

51 



802 DISLOCATIONS OF THE PHALANGES OF THE TOES. 

last two metatarsal bones, which was not at the time recognized. On the tenth 
day swelling commenced, and soon after the patient died in convulsions x 

Dr. W. C. Shaw, of Pittsburg, reports the case of a man 35 years old, who, 
falling from a height, "struck with all his weight upon a sharp edge of stone, 
striking upon the inner and under surface of the right metatarsal bones, dislo- 
cating the proximal end of the first metatarsal bone upward, and apparently 
carrying the second with it." After several ineffectual attempts at reduction 
made by himself and others, in which extension and direct pressure were em- 
ployed, he succeeded finally by " bending the foot to an acute angle on the inner 
surface, approximating the articulatiug surfaces of the dislocated bones, and 
quickly extending the foot." 2 



CHAPTEE XXV. 

DISLOCATIONS OF THE PHALANGES OF THE TOES. 

Dislocations of the toes are less common than those of the fingers, 
yet a considerable number of cases have been recorded by different sur- 
geons. They are occasioned by blows received directly upon the ends of 
the toes; by the weight of the body brought to bear suddenly upon their 
plantar surfaces, as when a horseman springs in his stirrups, or by a fall, 
in consequence of which the rider hangs in his stirrup ; by leaping,, etc. 
They may be partial or complete ; and in the latter case, a slight over- 
lapping is generally observed In a great majority of cases the direction 
of the displacement is backward, or with only a slight lateral deviation. 
Occasionally several bones are displaced at the same time, but usually 
only one suffers displacement. It is more common here to find compound 
and complicated dislocations than in the case of the fingers. 

The position of the toes is not always the same in the same form of 
dislocations. Thus, in the dislocation backward, the toe is sometimes 
reversed upon the foot to nearly a right angle, and at other times it is 
found lying in the same axis as the metatarsal bone, or the phalanx, 
from which it is dislocated. 

Some years since I reduced a backward dislocation of the first phalanx of the 
second toe in the person of L. B., aet. 60, who had fallen from a fourth-story 
window, striking upon his feet, and breaking both thighs. I did not discover 
the dislocation of the toe until sixteen hours after the accident. It was then 
lying parallel with the axis of the metatarsal bone, upon which it was slightly 
overlapped. The reduction was effected easily by pulling upon the last phalanx 
with my fingers, while at the same moment I pushed the head of the bone 
toward the socket. No swelling followed, nor has it troubled him at all since 
his recovery. 

Dr. John H. Packard, of Philadelphia, informs me that in a dislocation back- 
ward of the first phalanx of the great toe, occurring in a very muscular man, the 
phalanges w T ere found lying parallel with the metatarsal bone ; and it was reduced 
easily by extension, while the patient was under the influence of ether. 

Treatment. — With regard to the treatment, surgeons have experienced 
the same difficulty, in certain cases of dislocation of the great toe, as we 

1 Malgaigne, op. cit., p. 1077, et seq. 

2 Shaw, Pittsburg Med. Journ., 1882, p. 301. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 803 

have seen experienced in similar dislocations of the thumb. Occasionally, 
indeed, the reduction has been found to be impossible. The same doubts 
have existed also in relation to the causes of this difficulty, and in reference 
to the means by Avhich it was to be overcome. I shall, therefore, refer 
the reader to the chapter on Dislocations of the First Phalanges of the 
Thumb and Fingers, for a more full consideration of this matter. In 
case the smaller toes are dislocated, the reduction is generally eifected 
with ease, by simple extension, or by extension combined with pressure ; 
sometimes, also, the bone will be more easily put in place by reversing 
the phalanx more completely, as I have advised in certain cases of dislo- 
cations of the fingers. If the skin is penetrated, it will often be found 
necessary either to amputate or to practise resection upon the exposed 
phalanx. 

Sir Astley Cooper relates a case of dislocation of " all the smaller toes," from 
the metatarsus, which had not been reduced, and the subject of which was, in 
consequence, so much maimed that he was unable to labor. It had been occa- 
sioned by a fall, from a considerable height, upon the extremities of the toes. A 
projection existed at the roots of all the smaller toes, the extremity of each 
metatarsal bone being placed under the first phalanx of its corresponding toe. 
The swelling which immediately followed the receipt of the injury had concealed 
its nature, and now, several months having elapsed, reduction could not be 
effected. The only relief which could be afforded him, therefore, was in wearing 
a piece of hollow cork at the bottom of the inner part of the shoe, to prevent the 
pressure of the metatarsal bones upon the nerves and bloodvessels. 1 



CHAPTER XXVI. 

COMPOUND DISLOCATIONS OF THE LONG BONES. 

Frequency of Compound as compared with Simple Dislocations. — 
Compound dislocations, as compared with simple, are of rare occurrence. 
Of ninety-four dislocations reported by N'orris as having been received 
into the Pennsylvania Hospital for the ten years ending in 1840, only 
two were compound ; 2 and of one hundred and sixty-six dislocations in 
my record of personal observation made in 1855, only eight were com- 
pound. 3 

Relative Frequency in the Different Joints. — In my own recorded 
cases just referred to four were dislocations of the tibia inward at the 
ankle-joint, one was a partial (pathological) dislocation forward at the 
same joint, one a dislocation of the astragalus, one a dislocation of the 
head of the humerus into the axilla, and one a forward dislocation of the 
radius and ulna at the wrist-joint. I have also met with several examples 



1 Sir Astley Cooper, op. cit., p. 385. 

2 jSTorris, Amer. Journ. Med. Sci.. April, 1841, p. 335. 

3 For most of these cases, see Transactions of the K"ew York State Med. Soc. for 1855, 
article entitled " Eeport on Dislocations, with especial reference to their Results/' by F. EL 
Hamilton. 



804 COMPOUND DISLOCATIONS OF THE LONG BONES. 

of compound dislocations of the elbow and fingers. Both of the cases 
reported by Norris were dislocations of the thumb. 

Sir Astley Cooper, speaking upon this point, says that the elbow, wrist, ankle, 
and finger-joints are most subject to these accidents; and that he has seen but 
two in the shoulder-joint, and one in the knee-joint. He had never seen a com- 
pound dislocation at the hip-joint, and he believed that it was " scarcely ever" 
so dislocated. Malgaigne says that a compound dislocation at the hip-joint has 
probably never occurred. Mr. Bransby Cooper has, however, reported in detail 
a very interesting case of this accident, communicated to him by Dr. Walker, 
of Charlestown, Mass., in which reduction was accomplished by manipulation 
alone, by Dr. Ingalls on the second day. The patient died at the end of about 
three weeks. 1 I have already, when considering dislocations of the femur down- 
ward and backward, referred to the case reported by Dr. W. Taylor, in which 
reduction having been effected recovery took place. 

Among the cases of compound dislocation recorded by Sir Astley and Bransby 
Cooper, most of which were communicated to these gentlemen by other sur- 
geons, forty-five were dislocations of the ankle, ten of the astragalus, four of the 
ulna at the wrist-joint, four of the thumb, two of the knee, one of the shoulder, 
one of the elbow, one of the radius and ulna at the wrist, one of the scaphoid 
bone, and one of the metatarsal bone of the great toe. Other writers have occa- 
sionally described compound dislocations of the clavicle, but I know of no record 
of a compound dislocation of the lower jaw. 

Prognosis. — By most of the early writers these accidents, whenever 
they occurred in the larger joints, were regarded as nearly beyond the 
reach of art. Says Hippocrates : " In cases of complete dislocation at 
the ankle-joint, complicated with an external wound, whether the dis- 
placement be inward or outward, you are not to reduce the parts, but let 
any other physician reduce them if he choose. For this you should know 
for certain, that the patient will die if the parts are allowed to remain 
reduced, and that he will not survive more than a few days, for few of 
them pass the seventh day, being cut off by convulsions, and some- 
times the leg and foot are seized with gangrene." Hippocrates adds: 
" But if not reduced, nor any attempt at first made to reduce them, most 
of such cases recover.'"' 2 The same remarks are applied by Hippocrates 
to compound dislocations of the head of the tibia, of the lower end of the 
femur, of the wrist, elbow, and shoulder-joints ; death occurring in all 
cases, as he believed, more or less speedily whenever the bones are 
reduced and retained in place a sufficient length of time, and " were it 
not that the physician would be exposed to censure," he would not reduce 
even the bones of the fingers, since it must be expected, he thinks, that 
their articular extremities will exfoliate even when the reduction is most 
successful. Hippocrates advised and probably practised resection in cer- 
tain cases of these accidents. 

Both Celsus and Galen adopt almost without qualification the line of practice 
laid down by Hippocrates, and affirm equally the danger and almost certain 
death consequent upon the reduction of compound dislocations in large joints. 3 
Celsus recommends resection in some cases. Paulus iEgineta, however, and 
after him Albucasis, Haly Abbas, and Rhazes, do not regard the rules established 
by Hippocrates, in relation to the non-reduction of the bones, as so imperative, 
nor the results of the opposite practice as so uniformly fatal. " Hippocrates 

1 A. Cooper, on Dislocations, etc., by B. Cooper, p. 59. 

2 Works of Hippocrates, Syd; ed., London, vol. ii. p. 634. 

3 Paulus iEgineta, Syd. ed , vol. ii. p. 510. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 805 

remarks," says Paulus iEgineta, "in the case of dislocations with a wound, the 
utmost discretion is required. For these, if reduced, occasion the most imminent 
danger, and sometimes death, the surrounding nerves and muscles being inflamed 
by the extension, so that strong pains, spasms, and acute fevers are produced, 
more particularly in the case of the elbows, knees, and joints above, for the 
nearer they are to the vital parts the greater is the danger they induce. Where- 
fore, Hippocrates, by all means, forbids us to apply redaction and strong band- 
aging to them, and directs us to use only anti-inflammatory and soothing ap- 
plications to them at the commencement, for that by this treatment life may 
sometimes be preserved. But what he recommends for the fingers alone, we 
would attempt to do for all the other joints ; at first and while the parts remain 
free from inflammation, we would reduce the dislocated joints by moderate ex- 
tension, and if we succeed in our object, we may persist in using the anti-inflam- 
matory treatment only. But if inflammation, spasm, or any of the aforemen- 
tioned symptoms come on, we must dislocate it again if it can be done without 
violence. If, however, we are apprehensive of this danger (for perhaps, if 
inflammation should come on, it will not yield), it will be better to defer the 
reduction of the greater joints at the commencement ; and when the inflamma- 
tion subsides, which happens about the seventh or ninth day, then, having fore- 
told the danger from reduction, and explained how, if not reduced, they will be 
mutilated for life, we may try to make the attempt without violence, using also 
the lever to facilitate the process." 1 

In the following quotations from three of the most celebrated writers of the 
last two centuries, we find but little, if any evidence that the opinions of the 
fathers upon this subject were not still held in general respect: " If the joint be 
dislocated, so ihat it is either uncovered, or a little thrust forth without the skin, 
the accident is mortal, and of more danger to be reduced than if it be not re- 
duced. For if it be not reduced, inflammation will come upon it, convulsion, 
and sometimes death. 2. There will be a filthiness of the part itself. 3. An 
incurable ulcer, and if perhaps it be brought to cicatrize at all, it will easily be 
dissolved by reason of the softness of it ; but if it be reduced, it brings extreme 
danger of convulsion, gangrene, and death." 2 "Si vero in magnis articulis tarn 
valida fuit facta luxatio, ut ligamentis ruptis os articuli multum sit protrusum 
per integumenta, heec pars ossis vasis privata moritur, citius autum si reponatur, 
quam si non reponitur ; quare sola amputatio restat ad conservationem vitae." s 
Heister, who makes no allusion to this subject in the first edition of his great 
work, published at Amsterdam in 1739, adds the following remarks in his last 
edition, translated and published in London in 1768 : "Dislocations attended 
with a wound, especially of the shoulder or thigh-bone, are of very bad conse- 
quence, and often endanger the life of the patient ; in Celsus's opinion, whether 
the bones be replaced or not, there is generally great danger; and so much the 
more the nearer the wound is to the joint. Hippocrates has declared that no 
bones can be reduced with security, besides those of the hands and feet. See 
more on this subject in that passage of Celsus just now quoted, though I by no 
means recommend the following him implicitly." i 

Such were the extreme views as to the fatality of these accidents, and 
of the feebleness of our resources, entertained by the ancient, and even 
by the more modern writers almost clown to our own day ; with only rare 
exceptions these limbs were condemned either to great and inevitable 
deformity, or to amputation. Nor, if we speak only of their fatality, 
have surgeons ceased to regard these accidents as among the most grave 

1 Paulus iEgineta, Syd. ed., vol. ii. p. 509. 

2 Chirurgeon's Storehouse. By Johannes Scultetus, of Ulme, in Suevia. London ed., 
1674, p. 31. 

3 Johannes de Gorter. Chirurgia repurgata. Lugduni Batavorum, 1742, p. 86. 

4 General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768, vol. i. 
p. 164. 

See also, " De l'intervention Chir. dans lesLux. compliquees du cou-de-pied," by G. Poin- 
sot Paris. 1877. 



806 COMPOUND DISLOCATIONS OF THE LONG BONES. 

with which they have to deal. The danger, according to Sir Astley 
Cooper, consists in the rapid inflammation of the synovial membranes, 
which is speedily followed by suppuration and ulceration, whereby the 
ends of the bones become exposed ; and for the repair of which lesions 
great general as well as local efforts are required, and a high degree of 
constitutional irritation results. In addition to which circumstances, 
"the violence inflicted on the neighboring parts, the injury of the mus- 
cles and tendons, and the laceration of bloodvessels, necessarily lead to 
more important and dangerous consequences than those which follow 
simple dislocations." 

The sources of danger enumerated by Sir Astley Cooper have been regarded 
as sufficient to account for their extraordinary fatality by the majority of those 
modern surgical writers who have alluded to the subject; but I must confess 
that to me they do not appear so. In compound fractures the mortality is far 
less ; yet one might naturally suppose that when the sharp and irregular frag- 
ments are pressing into the flesh, among nerves and bloodvessels, the irritation 
and inflammation would be equal, if not more than equal, to the irritation and 
consequent inflammation produced by exposing a joint surface to the air ; indeed, 
modern experience has sufficiently shown that these surfaces are much more 
tolerant of atmospheric exposure, and of the action of many other irritants, than 
surgeons formerly supposed. A clean incision into a large joint, which exposes 
the synovial membranes to the air, and which permits the products of inflamma- 
tion to escape freely, is attended with much less danger than a small puncture 
which does not at all permit the air to enter, nor the increased synovia and the 
pus to escape. Very grave results sometimes follow from large wounds into large 
joints, but under judicious treatment such results are the exception and not the 
rule. 1 But Sir Astley evidently attributes more of the bad consequences to the 
exhausting effects of the efforts at repair, than to the immediate inflammation 
resulting from the exposure of the joint. If is pretty certain, however, that a 
majority of these patients die at a period too early to render this cause in any 
considerable degree operative. 

As to the bruising of the "muscles and tendons, and laceration of bloodves- 
sels," it cannot be denied that it must usually be greater than in "simple dislo- 
cations ;" and I will not say that it is not in a given number of instances greater 
than in the same number of instances of compound fractures. The tissues have 
often been thrust rudely through by a large and smooth bone, and the tendons 
have been stretched violently or torn completely asunder ; while occasionally 
large arteries, which are prone to hug the bones about the joints are lacerated 
and left to bleed. That the importance of these complications, however, may 
not be overestimated, I must state that Sir Astley Cooper himself has remarked 
how seldom, in compound dislocations of the ankle-joint, the large arteries are 
injured ; that a tearing of the ligaments and of the tendons is almost as likely to 
occur in simple dislocations as in compound ; and, indeed, that in neither case 
are the tendons usually ruptured, but only thrust aside. Moreover, the skin is 
often made to give way not so much from the pressure of the round head within, 
as from the equal pressure of some sharp angular body from without. In all 
these respects, there are many examples of compound fractures which possess 
not a whit of advantage ; in which cases, nevertheless, the surgeon feels very 
little doubt as to the ultimate cure. 

In short, the causes which, according to Sir Astley Cooper, determine the 
extraordinary fatality of these accidents, do not sufficiently differ from those 
which operate in compound fractures to occasion so great a difference in results, 
and the fatality of compound dislocations remains unexplained ; or, if surgical 

1 Upon this point, see the very able article, entitled "Amputations and Compound Frac- 
tures," by John 0. Stone, in the New Journal of Medicine, vol. iii.of 2d series, p. 316, Nov. 
1849 ; and also a paper entitled " De la conservation dans le traitement des fractures com- 
pliquees," by G. Poinsot, Paris, 1873. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 807 

writers have here and there intimated the true cause, they have failed to give it 
its proper place and value. 

The cause of the greater fatality of compound dislocations over com- 
pound fractures is to be found in the simple fact that dislocations are 
generally reduced, and by splints or other apparatus successfully main- 
tained in place, while compound fractures, as my statistical report of 
cases has proven, are not generally reduced completely, nor can they by 
any means yet devised, except in a few cases, be maintained in place if 
reduced. Broken limbs, whether simple or compound in their character, 
will in a great majority of cases shorten upon themselves in spite of the 
most assiduous and skilful attempts to prevent it. 1 

In adults most bones break obliquely, and cannot be made to support 
each other, and even in transverse fractures the broken ends are gener- 
ally small compared with the articular ends of the same bones, and afford 
a very uncertain and inadequate support for themselves ; not to speak of 
the difficulty of once bringing their ends into exact apposition where the 
muscles are powerful, or where they lie embedded in a large mass of flesh 
so that they eannot be felt. While, on the other hand, dislocated bones, 
whether simple or compound, are capable, when restored to place, of sup- 
porting themselves ; or with only slight assistance, their reduction may 
be maintained ; it is also ordinarily a work of no great difficulty to reduce 
them. Herein, then, consists the most important difference between these 
two classes of accidents, which are in other respects so similar. In the 
one, the very nature of the injury prevents the complete reduction, and 
the consequent violent strain of the muscles, tendons, and other soft tis- 
sues ; while in the other, the nature of the accident leaves it in the power 
of the surgeon to reduce the bones, and modern surgery has in a great 
measure sanctioned the practice of maintaining them in place, in defiance 
of the efforts of the muscles, and sometimes, no doubt, at the imminent 
hazard of the life of the patient. 

Is it not fair to presume that tissues which have been stretched and lacerated, 
require rest in order that they may recover from the effects of their injuries? 
And if the soft parts are really more injured in dislocations than in fractures, 
does not the indication for rest become for this very reason more imperative ? 

The shortening of limbs after fractures, within certain limits and in 
certain cases, is a conservative circumstance rather than one which the 
surgeon should, in all cases, seek to prevent. 

There is abundant evidence that the ancients had some knowledge of the value 
of rest to the muscles, tendons, etc., in the prevention of inflammation after com- 
pound dislocations, since they constantly urge the greater danger of reducing 
these dislocations, than of leaving them unreduced ; and they do not hesitate to 
recommend that, in case violent inflammation supervenes upon the reduction, 
the bone shall immediately be again dislocated. Galen speaks very explicitly 
on this subject, and says that "the danger in reduction consists partly in the 
additional violence inflicted on the muscles, and partly in their being put into a 
stretched state, whereby spasms or convulsions are brought on, and gangrene as 
the result of the intense inflammation which ensues ;" and Paulus iEgineta 

1 "Report on Deformities after Fractures." Trans. Amer. Med. Assoc, vols, viii., ix., 
and x. 



808 COMPOUND DISLOCATIONS OF THE LONG BONES. 

remarks : " For these, if reduced, occasion the most imminent danger, and some- 
times death; the surrounding nerves and muscles being inflamed by the exten- 
sion," etc. 

Treatment. — The alternatives which surgery presents for the treat- 
ment of these intractable accidents are as follows : 1. Reduction of the 
bone. 2. Non-reduction. 3. Amputation. 4. Tenotomy. 5. Resec- 
tion and reduction. The questions for us to consider are, first, by which 
of these several methods is the life of the patient rendered most secure ? 
and, second, when, of two or more methods, all are equally safe, by 
which will he suffer the least maiming or mutilation ? 

Reduction. — We have seen already how the old surgeons regarded the 
practice of reducing compound dislocations of the larger joints. It is not 
difficult, however, to find in the records of surgery numerous examples 
of successful terminations under this practice. 

Dr. White, of Hudson, N. Y., has reported a case of this kind in which the 
dislocation was at the ankle-joint. 1 Pott says he has seen this practice occasion- 
ally succeed, 2 and Mr. Scott reported 3 a case of compound dislocation of the 
humerus successfully treated by reduction. Sir Astley Cooper also records sev- 
eral cases of compound dislocations at the lower end of the tibia and fibula, suc- 
cessfully treated by reduction. 

A careful examination, however, of those cases reported by Sir Astley as 
having been reduced without resection, and which resulted in cures, does not, 
in my opinion, leave much substantial evidence in favor of the practice ; or per- 
haps I ought rather to say that it leaves only a qualified evidence of its pro- 
priety in certain cases. He has mentioned about sixteen of these examples, 
comprising dislocations of the lower end of the tibia, or of the tibia and fibula, 
outward, also inward and forward, all of which, save one quoted from Mr. Lis- 
ton, have been reported to him by other surgeons, and not one of which had he 
ever seen himself. Many of the cases are reported very loosely, evidently in 
reply to circular letters, and from memory, without recorded notes, and by un- 
known, and in some sense, irresponsible surgeons. It is not always said whether 
the wounds in the soft parts were made by the protrusion of the bones, or by 
some external violence; yet this is certainly a very material point in determin- 
ing whether reduction is to be followed by inflammation or not. The results, 
sometimes' only attained after exposure to great hazards, are, after all, often suf- 
ficiently unfavorable. 

It will be noticed, also, that, in Cases 152 and 153, the astragalus was commi- 
nuted and removed, either at first or at a later day; and in Cases 154, 155, 156, 
and 160, the tibia, and also probably the fibula, were broken, and it does not 
appear but that in consequence of this complication the limb became shortened, 
and the muscles were thus put at rest, very much as if the bones had been re- 
sected ; and in one of the cases enumerated under 161, the lower end of the tibia 
spontaneously exfoliated. That a comminution or that any fracture of the astrag- 
alus, or of the tibia and fibula, should be regarded in these cases as rendering the 
accident less grave, can only be comprehended by a full appreciation of the value 
of relaxation of the muscles. 

The few cases which remain after this exclusion do indeed illustrate 
how nature and skill may triumph over great difficulties, but nothing 
more. It is possible, also, that some of these examples of recovery after 
reduction may admit of an explanation entirely consistent with my own 
views of the true source of the danger in these accidents, if indeed they 
do not tend actually to confirm my doctrines. 1 have myself seen several 

i White, Amer. Journ. Med. Sci., Nov. 1828, p. 109. 

2 Pott, Chirurg. Works, vol. ii. p. 243. 3 Lancet, March, 1837. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 809 

examples of complete recovery after reduction of compound dislocations 
at the ankle-joint, although resection was not practised ; in one of which, 
all the tissues, or nearly all of which suffered any injury, were completely 
torn asunder, and therefore wholly removed from the danger of which I 
have spoken. 

The example referred to is the following : J. B., set. 30, was caught in the tow- 
line of a canal-boat, causing a compound dislocation of the right ankle-joint. I 
found the foot, immediately after the accident, thrown completely back against 
the lower part of the leg, the integuments in front of the joint, as well as all of 
the tendons and ligaments on this side, being completely torn asunder, while the 
tendo Achillis, and the tendons behind both of the malleoli, with the corre- 
sponding integuments, were uninjured. This immunity of the tissues behind 
the malleoli was due to the direction in which the foot was drawn, namely, 
directly backward. Everything which had suffered a strain being thoroughly 
severed, I did not hesitate to attempt to save the limb without resection. The 
reduction was accomplished very easily. The leg and foot were placed in a 
box filled with bran, and cool water dressings were applied to the portion which 
was exposed. On the twentv-second day the limb was removed from the bran 
to a pillow, the union being sufficient not to demand so much lateral support. 
He left the hospital, the wound having closed, but the ankle remaining swollen 
and stiff. 

I have also seen two cases in which the foot has been nearly severed from the 
leg through the ankle-joint, by means of a "reaper." In each case the patient 
was standing with his back to the machine, and one of the blades cut horizon- 
tally from side to side, severing everything except about three inches of integu- 
monts in front, and the extensor tendons of the toes. In the first instance, 
having seen the patient, a gentleman nearly 60 years of age, within three or four 
hours after the receipt of the injury, I found him exceedingly exhausted by the 
hemorrhage. Both malleoli were cut off smoothly, the knife having severed the 
limb so exactly through the joint, as to have incised the cartilage of incrustation 
at but one or two points. Having secured the bloodvessels, I replaced the foot, 
and after a few days of attendance I left him in charge of Dr. Robinson, of Lan- 
caster,]^. Y., to whose diligence and skill the patient is no doubt mainly indebted 
for his recovery. After the lapse of nearly one year he was able, by the assist- 
ance of a shoe furnished with lateral supports, to walk very well. In the second 
case, which was only brought to my notice some months after the accident 
occurred, in consequence of a troublesome fistula near the ankle-joint, the 
recovery had been complete except that a small fragment of one of the malleoli 
was necrosed and required removal. 

Dr. Hurd, of Niagara Co., N. Y., was equally fortunate in a case of compound 
dislocation of the shoulder-joint. This was in the person of G. T., set. 30, who 
was caught in the gearing of a threshing-machine, which, having drawn him in 
with great force, dislocated the head of the left humerus downward through the 
integuments into the axilla. Reduction was accomplished according to the 
method recommended by Nathan Smith, by pulling from each wrist at right 
angles with the body, while the operator himself seized the naked head of the 
humerus with his left hand, his right resting upon the top of the shoulder, and 
pushed it into place. The time occupied in the reduction was about thirty 
seconds. The forearm was then suspended in a sling, and the venous hemor- 
rhage, occasioned by a rupture of the subclavian vein, was arrested by compres- 
sion. The tegumentary wound, between three and four inches in length, was 
subsequently closed by sutures, and cool water dressings were applied. On the 
fourth day the wound had united by first intention, and the man was walking 
about his room. In less than a month he was dismissed cured, and in the fol- 
lowing harvest he was able to cut his own hay and grain, and to use his arm as 
before the accident. 1 

Miller and Hoffman reduced successfully a compound dislocation of the knee, 2 



1 Hurd, Buffalo Med. Journ., vol. ix. p. 119. 

2 Miller and Hoffmann, London Med. Eepos., vol. xxiv. p. 346. 



810 COMPOUND DISLOCATIONS OF THE LONG BONES. 

and Galli has communicated a similar case to Malgaigne. 1 Whether either of the 
last three mentioned examples admit of the same explanation as the preceding 
three, I am unable to say, but whether they do or do not, they are too excep- 
tional in their character to prejudice materially the argument which I shall here- 
after make in favor of resection. 

It is not pretended that the few cases which I have mentioned in 'the 
preceding pages are all of the compound dislocations of the larger joints, 
successfully treated by reduction, which have been recorded; nor are 
they all which have come under my own observation ; nevertheless, I 
repeat, success by this method has up to this moment, whatever plan of 
after-treatment has been adopted, been found to be the exception and 
not the rule. I speak now more especially of those dislocations of this 
class, which are rendered compound by the thrusting of the dislocated 
bone through the flesh, and which, in my experience, constitute by far 
the largest proportion of these examples. 

Non-reduction. — While it is true that not many cases of, compound 
dislocations, especially of the larger joints, can be found recorded as 
having terminated favorably after reduction, yet it will be very difficult 
to find an equal number of cases of compound dislocations, unreduced, 
which have terminated favorably. The fact is, no doubt, that at the 
present day very few surgeons would feel themselves justified in leaving 
a bone out of place unless they proceeded to amputate. 2 

I have reported a compound dislocation at the ankle joint, which, being unre- 
duced, terminated fatally on the twenty-eighth day. This is the only example 
of a compound dislocation of a long bone, left unreduced, which has fallen under 
my observation ; excepting, of course, those cases in which amputation was 
immediately practised. 

The united testimony, however, of the old surgeons, who generally 
neither amputated nor adopted the method of resection, but who recom- 
mended and practised non-reduction, is, that it is much more safe to 
leave these bones unreduced, than to attempt immediate reduction ; and 
I see no reason to doubt the correctness of their opinions in this matter. 
But whether it would be more safe to leave such limbs unreduced, or 
having practised resection to restore them, is another question, in which 
the advantage and comparative safety of the latter practice are too obvious 
to require explanation or defence. 

Amputation. — Says Pott : " When this accident (dislocation of the 
ankle) is accompanied, as it sometimes is, with a wound of the integu- 
ments of the inner ankle, and that made by the protrusion of the bone, 
it not unfrequently ends in a fatal gangrene, unless prevented by timely 
amputation, though I have several times seen it do very well without." 
And Sir Astley Cooper, speaking of compound dislocations of the ankle- 
joint, remarks : " Thirty years ago it was the practice to amputate limbs 
for this accident, and the operation was then thought absolutely neces- 
sary for the preservation of life, by some of our best surgeons." Nor 
is it difficult to see by what reasoning surgeons of " thirty years ago" 
had fallen back upon this desperate remedy. Both reduction and non- 

1 Gralli, Malgaigne, op. cit., torn. ii. p. 958. 

2 Transactions of the New York State Medical Society, 1855. 



COMPOUND DISLOCATIONS OF THE LONG BONES, 811 

reduction having proven eminently hazardous, in the absence of perhaps 
both knowledge and experience in resection, they finally adopted the 
alternative of amputation, as that which after all must give to the patient 
the best chance for life ; and were no other alternatives to be presented, 
this would be my choice in a large proportion of cases. It must not be 
understood, however, that amputation is an expedient wholly free from 
danger ; or, indeed, that the chances of the patient are, in the average, 
very greatly increased by this practice. 

Of thirteen amputations made for compound dislocations at the ankle-joint, 
in the Royal Infirmary at Edinburgh, only two resulted in the recovery of the 
patients. 1 Alluding to which, Mr. Fergusson remarks: "An amount of mor- 
tality which may well incline the surgeon to act upon the doctrine inculcated 
by Sir Astley Cooper " (to attempt to save the limb by reduction). But Mr. 
Fergusson has added a sentiment which accords very closely with my own 
experience and opinions. " I fear, however, that in the attempts which have 
been made to save the foot (by reduction), the results in all the cases have not 
met with the same publicity — that the instances where amputation has been 
afterward necessary, or where death has been the consequence, have not always 
been recorded; and, from what I have myself seen, I would caution the inex- 
perienced practitioner from being over-sanguine in anticipating a happy result 
in every example." 

Tenotomy. — As a means of overcoming the resistance of the muscles, 
and for the purpose especially of facilitating the reduction, tenotomy has 
been proposed ; first by Dieffenbach in cases of ancient unreduced dis- 
locations. But Wm. Hey, Jr., was the first to make a practical applica- 
tion of this suggestion in a case of compound dislocation. After cutting 
the tendo Achillis, the ankle being dislocated, the reduction was easily 
effected, but a strong tendency to displacement backward remained, and 
he was obliged afterward to cut the tendons of the tibialis posticus and 
flexor longus digitorum. 2 

This method, based in some degree upon a very correct notion of the 
principal sources of difficulty, I regard as in most cases totally imprac- 
ticable, at least to any useful or adequate extent. In order -to be efficient, 
usually, all the tendons passing the articulations must be cut, or nearly 
all of them ; and I doubt whether the judgment of any discreet surgeon 
will ever sanction such an extreme measure. Nor do I think that in the 
point of view in which I am now considering this subject, having ref- 
erence only to the question of danger, if the cutting of the tendons was 
sufficiently extensive to have any real effect in facilitating the reduction, 
the practice would be found to have any advantage over other methods 
known to be eminently dangerous. Certainly in no case would the 
surgeon, in my opinion, be justified in cutting any other than the tendo 
Achillis. 

Resection. — Resection presents itself for our consideration as the only 
remaining surgical expedient. Most of the early writers understood the 
effects of a constant strain upon the muscles in increasing the danger of 
spasms, inflammation, and death ; but in general they have suggested no 
remedy but non-reduction or amputation. 

^Edinb. Med. Monthly, Aug. 1844. 

2 Hey, Trans, of Provinc. Med. and S.urg. Assoc, vol. xii. p. 171, 1844. 



812 COMPOUND DISLOCATIONS OF THE LONG BONES. 

Hippocrates, however, uses the following language, after speaking of resection 
of protruding bones in accidental amputations or in fractures of the fingers : 
" Complete resection of bones at the joints, whether the foot, the hand, the leg, 
the ankle, the forearm, the wrist, for the most part, are not attended with danger, 
unless one be cut off at once by deliquium animi, or if continued fever super- 
vene on the fourth day." To which passage the translator adds the following 
note: "This paragraph on resection of the bones in compound dislocations and 
fractures contains almost all the information on the subject which is to be found 
in the works of ancient medicine." Celsus notices the practice of resection in 
compound dislocations very briefly as follows: " Si nudum os eminet, impedi- 
mentum semper futurum est; ideo quod excedit, abscindendum est." 

Mr. Hey, of Leeds, was the first of modern surgeons who called especial atten- 
tion to the value of resection in compound dislocations. Subsequently, Mr. 
Parks, of Liverpool, in an " Account of a New Method of Treating Diseases of 
the Joints of the Knee and Elbow/' advocated the practice of resection in certain 
cases of diseases of these joints, but especially in '' affections of the joints pro- 
duced by external violence." M. Leveille, in France also, following, as he 
affirms, the guidance of Hippocrates, has advocated a similar practice. 

Velpeau, Syme, Fergusson, Erichsen, Miller, Liston, Chelius, Lizars, Gibson, 
Norris, under certain circumstances, and especially where the bones cannot 
otherwise be reduced, and where the dislocations occur in certain joints, and 
especially the elbow and ankle-joints, recommend resection. To which names I 
may add that of Sir Astley Cooper, who has considered the subject, as applied 
to the ankle-joint, quite at length, and who says: " 1 have known no case of 
death when the extremities of the bone" (tibia, at the ankle) " have been sawed 
off, although I shall have occasion to mention some cases which terminated 
fatally when this was not done." 

Why resection should diminish the danger to life, by placing at rest 
the injured muscles, has been already sufficiently considered; but it 
seems not improbable that, if the synovial membranes are actually more 
susceptible of violent and dangerous inflammation than the other tissues 
about the joints, then would this source of danger be removed just in 
proportion as the synovial membranes themselves are removed. Such, 
indeed, was the argument used by Sir Astley ; and Mr. South, in a note 
to Chelius, when referring to this fact, has made the following statement : 
"In compound dislocations of the ankle-joint, with protrusion of the 
shin-bone through the wound, most English surgeons saw off the joint 
end, not merely to render reduction more easy, but also, according to 
Sir Astley Cooper's opinions, to lessen the suppurative process, by dimin- 
ishing the synovial surface. This mode of practice is certainly not com- 
monly followed in reference to other joints, and the younger Cline was 
always opposed to its being resorted to in dislocated ankle." 

The following cases having occurred under my own eye, will serve to illustrate 
the value of the principle which I have been endeavoring to establish: S. A., 
set. 24, was caught by the cable of a vessel, dislocating the left tibia at its lower 
end inward, and breaking the fibula two inches above the ankle. I was imme- 
diately called, and found the tibia protruding through the skin about three 
inches. The periosteum was torn up, and the cartilaginous surface of the end 
of the bone was roughened. His thigh was also severely bruised and lacerated, 
but the bone was not broken. Dr. Boardmann assisting me, we attempted to 
reduce the bones, but with our hands we found it impossible to do so. I pro- 
ceeded immediately to remove about one inch and a half of the lower end of 
the tibia with the saw. The remaining portion was then brought easily into 
place, and the wound dressed with sutures, adhesive strips, bandages, and light 
splints. The wound in the leg healed kindly, with only a slight amount of 
inflammation and suppuration. Violent inflammation, however, occurred in the 
thigh, followed by extensive suppuration and sloughing. This, in fact, proved 



COMPOUND DISLOCATIONS OF THE LONG BONES. 813 

to be by far the most serious injury, and that which most endangered his life 
and delayed his recovery. After about two months, the ankle was in such a 
condition as to require little or no further attention. The fragments of the 
fibula had shortened upon each other and were united, so that the tibia rested 
upon the astragalus. It was nearly two months^ however, before he began to 
walk, owing to the condition of his thigh. Fourteen months after the accident 
he called at my office. He was then employed again as a sailor on board the 
schooner Sebastopol, and performed all the duties of an ordinary deck-hand. 
His leg is shortened one inch and a quarter ; from which it seems that there has 
been some deposit upon the end of the bone, which has compensated for one 
quarter of an inch of that which I removed. The ankle is perfect in its form, 
being neither turned to the right nor to the left, and he treads square and firm 
upon the sole of his foot. There is considerable freedom of motion, especially 
in flexion and extension. Occasionally it becomes a little swollen and painful. 

January 1, 1875, B. W., set. 45, was admitted to ward 13, Bellevue Hospital, 
having just been injured by a street-car. She was in good health, but very fat, 
weighing 185 lbs. She was found to have a compound dislocation at the right 
ankle-joint — the tibia being thrust completely through the flesh — and also a 
fracture of the fibula. Dr. Lewis, the house surgeon, reduced the dislocation at 
once, and easily, and then sent for me. I advised an attempt to save the limb 
without resection, and by supporting the limb with the plaster- of-Paris dressing. 
This dressing was applied fourteen hours after the accident by Dr. Lewis, a 
window being made opposite the ankle. January 3, the window was enlarged. 
January 5, gangrene and phlebitis had occurred ; fenestra again enlarged. 
January 7, entire splint laid open, and hot-water dressings applied. January 
12, suspended limb. January 21, the condition of the limb very critical; and, 
in a consultation composed of the visiting surgeons, we were equally divided 
between amputation and resection. It was permitted, therefore, that I should 
choose my own course. I immediately resected two inches of the lower end of 
the tibia, and placed the limb again in a sling supported with compresses as 
means of lateral support, and warm-water dressings were continued. The sub- 
sequent progress of the case was very slow, and there were several smart attacks 
of erysipelas, so that her life was at times in danger; but finally all unfavorable 
symptoms disappeared, and on the first of May, the ankle was in perfect shape, 
admitting of some flexion and extension, and the wounds were almost com- 
pletely closed. It is now apparent that a resection on the first day would 
have been the most judicious practice, but that even at a later day it saved her 
life. 

.In a case of compound dislocation of the upper end of the humerus, occurring 
also under my own observation, 1 in which reduction was followed by death, I 
have now much reason to believe that if I had practised resection before the 
reduction, my patient's chances for recovery would have been greatly increased ; 
perhaps also the case of compound dislocation of the wrist-joint recorded in the 
same volume (p. 68), in which, having reduced the bones, I was subsequently 
compelled to amputate, may equally illustrate the hazard to which the practice 
of reduction without resection must often expose the patient. The same remarks 
I will venture to apply to the case of compound dislocation of the hip, of which 
I have already spoken as having occurred in the practice of Dr. Walker, of 
Charlestown, Mass. Had the head of the femur been resected before its reduc- 
tion, I cannot doubt that the unfortunate man's chance for recovery would have 
been very greatly improved. 

Thus, if we consider the question of the life of the patient only, the 
argument and the testimony seem to favor resection, in a great majority 
of cases of compound dislocations occurring in large joints, and in a con- 
siderable number of cases of similar accidents in the smaller joints. It 
is certainly more safe than non-reduction or reduction without resection, 
and it is probably quite as safe as amputation. 



1 Trans. New York State Med. Soc, 1855, p. 27, ease 14. 



814 COMPOUND DISLOCATIONS OF THE LONG BONES. 

Poinsot, who has collected 82 reported cases of immediate resection practised 
for compound dislocations of the ankle-joint, found 68 cures, 10 deaths, and 4 
secondary amputations, of which latter one was cured, two died, and the result 
in the fourth was unknown. 

But there is another question, which is, in my estimation, secondary 
to the one now considered, but which is often, in the estimation of the 
patient himself, of the first importance, namely, by which method will he 
suffer the least maiming or mutilation ? This question I do not find it 
difficult to answer. Certainly it is not by non-i eduction or amputation ; 
and, putting tenotomy aside, it is now T a- question only between reduction 
without resection, and reduction with resection. These two methods, one 
of which experience has shown to be fraught with danger, and the other 
of which experience has shown to be relatively safe, are now T to be com- 
pared in a point of view in which their antagonisms are perhaps less con- 
spicuous, yet sufficiently marked. 

First. In either case the inflammation consequent upon the injury may 
be violent, and the recovery slow and tedious. The same arguments, 
however, which I have applied to the question of the comparative danger 
of the two modes, must apply with nearly equal force to this question of 
maiming ; since the amount of maiming must often be governed by the 
intensity and duration of the inflammation, and upon this point the testi- 
mony has been shown to be in favor of resection. Not only is the danger 
of maiming rendered more considerable by reduction without resection, 
because the inflammation is so much more likely to extend to the tendons 
and muscles, causing them to adhere to each other, and to become sub- 
sequently atrophied, a condition from which they often never completely 
recover ; but also because the ligaments and capsules of the joints, with 
the synovial surfaces, are in consequence encroached upon, and the free- 
dom of motion is ever afterward greatly restricted, if not completely lost. 
This marked impairment of the functions of the joint does not always 
happen, but it cannot be denied that it does generally.* Indeed, it is by 
no means uncommon for these accidents to be followed, after ulcerations 
of the cartilage, by copious bony deposits in and around the joints. How 
is it, on the other hand, with these joints after resection ? I have thus 
far heard of no cases in which complete ankylosis resulted ; but in all 
considerable freedom of motion has returned, and in some the restoration 
in this respect has been nearly or quite as complete as before the accident. 

Poinsot has also made a very careful resume of the results of resection in regard 
to the usefulness of the limb. In forty-one cases where the patients have been 
seen after complete recovery there is not a single failure ; only it is observed 
that in the case of Oilier, there existed a slight deviation of the foot backward, 
which was corrected by apparatus. In all of these cases the patients walked 
well, and were able to resume their previous occupations; A. similar analysis 
made by the same writer, of examples treated by reduction and without resec- 
tion, gave the following results: In nineteen of twenty-three cases, the patients 
could walk without artificial support; in one case the aid of a cane or of other 
support was required; three times the foot was ankylosed in a vicious position, 
and remained painful, and the patients were obliged to ask for surgical inter- 
ference; in two of these latter cases amputation was practised, and in one resec- 
tion, the resection restoring to the patient a useful limb. 1 

1 Poinsot, op. cit v p. 1238. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 815 

Kerr, of Northampton, says: "Several cases of compound dislocation of the 
ankle have fallen under my care, and it has been uniformly my practice to take 
off the lower extremity of the tibia, and to lay the limb in a state of semiflexion 
upon splints; by this means a great degree of painful extension and the conse- 
quent high degree of inflammation are avoided. The splints I used are exca- 
vated wood, and much wider than those in cotnmoa use, with thick movable 
pads stuffed with wool. I keep the parts constantly wetted with a solution of 
liquor ammonise acetatis, without removing the bandage. In my very early life, 
upwards of sixty years ago, I saw many attempts to reduce compound disloca- 
tions without removing any part of the tibia ; but, to the best of my recollection, 
they all ended unfavorably, or, at least, in amputation. By the method which 
I have pursued, as above mentioned, I have generally succeeded in saving the 
foot, and in preserving a tolerable articulation." 

Sir Astley Cooper has made a valuable experiment to determine the condition 
of the new joint under these circumstances; and the vast number of examples 
in which resection has now been practised in cases of caries of the articulating 
surfaces, and their results, add still more substantial proofs as to the usefulness 
of the joints after such operations. "I made an incision upon the lower 
extremity of the tibia, at the inner ankle of a dog, and, cutting the inner por- 
tion of the ligament of the ankle-joint, I produced a compound dislocation of 
the bone inward. I then sawed off the whole cartilaginous extremity of the 
tibia, returned the bone upon the astragalus, closed the integuments by suture, 
and bandaged the limb to preserve the bone in this situation. Considerable 
inflammation and suppuration followed ; and in a week the bandage was re- 
moved. When the wound had been for several several weeks perfectly healed, 
I dissected the limb. The ligament of the joint was still defective at the part at 
which it had been cut. From this sawn surface of the tibia there grew a liga- 
mento cartilaginous substance, which proceeded to the surface of the cartilage 
of the astragalus to which it adhered. The cartilage of the astragalus appeared 
to be absorbed only in one small part; there was no cavity between the end of 
the tibia and the cartilaginous surface of the astragalus. A free motion existed 
between the tibia and astragalus, which was permitted by the length and flexi- 
bility of the ligamentous substance above described, so as to give the advantage 
of a joint where no synovial articulation or cavity was to be found. This experi- 
ment not only shows the manner in which the parts are restored, but also the 
advantage of passive motion ; for, if the part be frequently moved, the interven- 
ing substance becomes entirely ligamentous ; but, if it be left perfectly at rest 
for a length of time, ossific action proceeds from the extremity of the tibia into 
the ligamentous substance, and thus produces an ossific ankylosis.'' 

Second. Is it not probable, moreover, since the limb can be retained 
in place so much more easily after resection, that it will actually, in a 
majority of cases, be found to have been retained in place more perfectly? 
Even after simple dislocations, especially in those occurring at the ankle- 
joint, great deformity and much maiming are the not unfrequent results, 
and that, too, when all diligence and care have been employed. It has 
been impossible always to maintain a perfect apposition in the articulating 
surfaces. How much greater must be this difficulty in cases of compound 
dislocations. 

Third. The only argument which remains in favor of reduction with- 
out resection is the necessary shortening of the limb after resection. 
But this need seldom perhaps exceed three-quarters of an inch, and 
often not more than half an inch ; an amount of shortening which, as I 
have had occasion to prove when treating of fractures, does not neces- 
sarily produce a halt, and which indeed is often not known to exist by 
the patient himself. 

It is claimed that the experience of Heine, Langenbeck, Volkmann, Hueter, 
and other German surgeons, has shown that in a considerable number of cases, 



816 COMPOUND DISLOCATIONS OF THE LONG BONES. 

when these resections have been made by the subperiosteal methods, no shorten- 
ing whatever has resulted. 1 

Fourth. It must not be inferred that the author intends to recommend 
resection as a universal practice in cases of compound dislocations of the 
long bones. He has only sought to determine in a general manner its 
relative value as compared with other modes of procedure; and especially 
has it been his intention to bring more prominently into view the impor- 
tance of rest and relaxation to the muscles, as an element in the treat- 
ment most essential to success. To declare its special application to cases 
would demand a treatise more elaborate than it was proposed to write. 
If, however, one were to speak of the individual bones only, there seems 
sufficient authority in the facts and arguments already presented, to con- 
clude that resection is applicable to certain compound dislocations of the 
clavicle, humerus, radius, and ulna, fingers, femur, tibia, fibula, and toes; 
in short, to a certain proportion of all these accidents occurring in the 
long bones of the extremities. If an attempt is made to save the limb 
without resection, it is scarcely necessary to say that the success will 
depend, in a great measure, upon the care, attention, and skill bestowed 
upon the treatment. The limb must be maintained in a position of rest, 
combined with moderate elevation ; and warm- water or other suitable 
dressings assiduously applied; including a judicious employment of anti- 
septic precautions and of drainage. 

[It is necessary to emphasize the concluding words of the above text, recom- 
mending " a judicious employment of antiseptic precautions and of drainage." 
The question of the method of procedure in any given case of compound disloca- 
tion must be greatly influenced by the certainty that suppuration will not be 
present as a complicating condition. The treatment by reduction, if undertaken 
with the thorough employment of antiseptics, is deprived of nearly all these 
dangers. Resection performed aritiseptically is an entirely safe operation. 
While, therefore, the dangers of both reduction and resection, performed with- 
out antiseptic precautions, are not overstated by the older authorities, both oper- 
ations are now entirely practicable if the usual antiseptic remedies are employed. 

Of the several methods of treatment given, there can be no doubt that reduction 
is preferable provided it is equally safe. As the use of antiseptics removes the 
principal element of danger, reduction should, therefore, be the treatment pur- 
sued ordinarily. Resection should be resorted to only in cases in which the 
bones or other structures have been so much injured as to endanger the integrity 
of the joint, or in which reduction is impossible without excision. Amputation 
should be reserved for those cases in which the destruction of the vessels and 
nerves is such as to involve the loss of the extremity: 

The rule of practice should be as follows: 1. Determine the amount of injury 
which the structures about the joint have sustained. If the vessels and nerves 
are so far uninjured that the limb can be saved, determine upon reduction or 
resection. 2. In either case, cut away tissues so bruised or torn that death is 
likely to ensue. Disinfect all the exposed surfaces with hot sublimate solutions 
(1 : 4000), the water being injected forcibly with a bulb-syringe. The solution 
should be of a temperature of not less than 130° to 140°, or so that the hand can 
scarcely be retained in it. If of the proper temperature the irrigated tissues will 
be changed to a dull gray color. The greatest care is necessary to force this 
solution into every part of the joint, and among the tissues. 3. Reduction or 
resection should now be effected with little strain upon the tissues. 4. Ample 
drainage should be provided, the drainage-tube or tubes extending to every 

1 On Subperiosteal Eesection of the Tibio-tarsal Articulation. By Achilles Rose, M.D., 
New York. The Medical Record, July 3, 1875. 



CONGENITAL DISLOCATIONS. 817 

recess. 5. The wound should be closed by the union with suture of all divided 
tissues which can^ be brought into easy apposition. 6. Antiseptic dressings, 
enveloping the parts sufficiently, should be applied ; and to maintain rest a 
plaster-of- Paris dressing may be required, as at the knee or ankle. 

These dressings should not be changed for three or four weeks, unless there is 
evidence of disturbance in the wound. The tubes should be removed in four or 
five days by opening fenestra where they are located.] 



CHAPTEE XXVII 



CONGENITAL DISLOCATIONS. 

Congenital Dislocations are generally, in some sense, pathological, 
or are accompanied with such essential modifications of the anatomical 
structures as to separate them entirely from ordinary traumatic disloca- 
tions, which alone constitute the proper subjects of consideration in the 
present treatise. In relation to congenital dislocations, we shall find it 
necessary to establish systems of etiology, symptomatology, prognosis, 
and treatment, having very few points in common with traumatic dislo- 
cations. Exceptions to this rule will occur, in examples of intra-uterine 
traumatic dislocations, existing at birth without either original or acci- 
dental malformations of the articulations, or of the adjacent muscular, 
tendinous, or ligamentous structures ; yet only in sufficient numbers to 
warrant the intrusion of the subject in this place. 

It is probable that congenital displacements may occur in all the artic- 
ulations of the skeleton ; and in most of them their existence has been 
already established by dissections. Until within a few years, however, 
the attention of surgeons has been almost entirely directed to congenital 
dislocations of the shoulder and hip. 

Hippocrates, in his treatise " De Articulis," speaks expressly of dislocations of 
the hip occurring in the mother's womb, comprising them under the same order 
with the different varieties of club-foot. Avicenna and Ambrose Pare have each 
mentioned congenital dislocations of the hip; but the first to record an example 
with any degree of accuracy was Kerkring ; in which case, death having occurred 
during infancy, he was able to verify his opinion by an autopsy. Chaussier has 
reported, in the Bulletin de la Faculte et de la Societe de Medecine, An. 1811 and 
1812, the case of an infant, upon which he discovered, at birth, two dislocations, 
one at the scapulo-humeral articulation, and the other at the coxo-femoral. In 
1788, Palletta, of Milan, published, under the title of Adversaria Chirurgica, a 
collection of observations, in which, among other things, he has described cer- 
tain congenital malformations of the hip-joint ; and in 1820 he published another 
work, entitled Exercitationes Pathological, where he enters into a more complete 
exposition of the nature and causes of these deformities. In 1826, Dupuytren 
read, before the Academy of Sciences, a memoir upon the lameness produced by 
the original displacement of the femur ; and in the Legons Orales, published in 
the collections of the Sydenham Society, may be found a full record of the views 
and observations of this distinguished surgeon. The writings of Dupuytren 
seem, more than anything previously written, to have directed the attention of 
surgeons and pathologists to this interesting subject, and to have given a new 
impulse to investigation. 

52 



818 CONGENITAL DISLOCATIONS. 

From this time various treatises have been written by eminent surgeons, many 
of which are characterized by profound thought, careful investigation, and prac- 
tical experiment. Among those who have furnished us with elaborate treatises, 
or with more precise practical information upon this subject, the following names 
deserve to be especially mentioned: Breschet, 1 Caillard-Billioniere, 2 Lehoux, 3 
Sandiforte,* Bouvier, 5 Sedillot, 6 Wrolik, 7 Guerin, 8 Parise, 9 Pravaz pere, 10 Gar- 
nochan, 11 Robert Smith, 12 Delpech, 13 Heine, 14 von Amnion, 15 Pravaz fils, 16 Hueter, 17 
Dollinger, 18 Grawitz, 19 Kirmisson, 20 Kronlein, 21 Gerdy, 22 Poliniere, 23 Jalade- 
Lafond, 24 Humbert and Jacquier. 25 

Etiology. — If we analyze the various opinions of authors as to the 
causes of congenital dislocations, we shall find that they are so far sus- 
ceptible of classification, as that they may be arranged under the three 
following divisions : 

First, the physiological doctrines ; according to which congenital dis- 
locations are due to an original defect in the germ, or to an arrest of 
development. 

Second, the pathologic doctrines ; which refer them to some supposed 
lesion of the nervous centres, to contraction or paralysis of the muscles, 
to a laxity of the ligaments, to hydrarthrosis, or to some other diseased 
condition of the articulating apparatus. 

Third, the mechanical doctrines ; which recognize no intra-uterine dis- 
locations except those which are strictly traumatic, the causes being 
understood to be the peculiar position of the foetus in utero, violent con- 
tractions or the constant pressure of the walls of the uterus, falls and 
blows upon the abdomen, and unskilful manipulation of the child in de- 
livery. 

Hippocrates says that the several bones of the extremities may be disartic- 
ulated during intra-uterine life by falls or blows, or by injuries of any kind, 
inflicted directly upon the abdomen of the mother. Ambrose Pare, while ad- 
mitting the efficiency of the several causes named by Hippocrates, believed also 

1 Breschet, Repertoire d'Anatomie et de Physiologie. ' Gaz. Med., Paris, 1834, p. 218. 

2 Caillard-Billioniere, These Inaugurale, 1828. 

3 Lehoux, These Inaugurale, 1834. Paris. 

4 Sandiforte, Thesis, sustained before the Faculty of Med. of Leyden, 1836. 

5 Bouvier, Malad. Chron. de ap. Locomot., Paris, 1858. 

6 Sedillot, Journ. de Connais. Med.-Chirurg., 1838. 

7 Wrolik, Amsterdam, 1849, quoted by Pravas. 

8 Guerin, Eecherches sur les Luxations Congenitales ; par Jules Guerin. Paris, 1841. 

9 Parise, Archiv. Gen. de Med., 1842. 

10 Pravaz pere, Traite Theoriqueet Pratique des Luxations Congenitales du Femur, suivi 
d'un Appenpice sur la Prophylaxie des Luxations Spontaneesj par Ch. G. Pravaz. Lyons, 
1847. 

11 Carnochan, A Treatise on the Etiology, Pathology, and Treatment of Congenital Dis- 
locations of the Head of the Femur; by John Murray Carnochan. New York, 1850. 

12 P. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Certain Accidental 
and Congenital Dislocations. Dublin, 1854. 

13 Delpech, Orthomorphie, Paris, 1829, t. 2. 

14 Heine, Spont. und Congen. Lux , Stuttgard, 1842. 

15 Von Ammon, Die Angebornen Chir. Krankheiten der Menschen, etc.. Berlin, 1842. 

16 Pravas fils, Lux. Congen. du Femur, Lyon, 1847. 

17 Hueter, Klin, der Gelenkkrankheiten, Leipzig, 1870-71. 
is Dollinger, Arch. f. klin. Chir., Bd. 20, 1887. 

19 Grawitz, Virchow's Archiv, Bd. 74, Hft. l,p. 1, 1878. 

20 Kirmisson, Rev. Men. de Chir., 1878, p. 498. 

21 Kronlein, Die Lehre von der Lux., Deutsche Chir., v. Billroth u. Leucke, 1882. 

22 Gerdy, Rap. sus deux Mem. du Pravas, etc., Lyon, 1840. 

23 Poliniere, quoted by Pravas. 

24 Jalade-Lafond, Deform, du Corps Humain, etc., Paris, 1829. 

25 Humbert and Jacquier, de Lux. Spont. ou Symptomatiques, Paris, 1835. 



CONGENITAL DISLOCATIONS. 



819 



that the contractions of the womb, and violence employed by the accoucheur, 
were occasionally adequate to the production of the same result. He taught, 
moreover, that the position of the foetus itself might favor the displacement ; 
and that, in some instances, an articular abscess, insufficient depth of the socket, 
with a laxity of the ligaments, were competent to determine the expulsion of 
the head of the femur from its natural position. Sedillot regards a softening 
and relaxation of the ligaments as the most frequent cause. 

Parise and Malgaigne are disposed to attribute a majority of these cases to 
hydrarthrosis, or water in the joints. Says Malgaigne: "For myself, after 
having long meditated upon this subject, I have come to think that inflamma- 
tion of the joints enjoys a grand role, both in coxo-femoral dislocations and in 
many others,, and even also in various congenital malformations generally 
ascribed to arrest of development." This writer admits, however, that it will 
not do to generalize too much in this matter, and that the etiology of congenital 
dislocations is probably as complex as that of dislocations after birth. Dupuy- 
tren thought forced flexion of the thigh in utero would explain the congenital 
dislocations of the hip ; while Roser 1 attributes it to forced adduction. 

Chaussier seems to have regarded muscular contraction, or the occurrence of 
an intra-uterine convulsion, as the cause of the example of congenital disloca- 
tion of both humerus and femur seen and recorded by him. Since whom 
Guerin has greatly extended the application of this doctrine, having embraced 
in the same etiologic formula all or nearly all congenital dislocations. Guerin 
ascribes to muscular contraction in one form or another, and to corresponding 
muscular paralysis, not only dislocations of the femur and other long bones, but 
also club-foot, torticollis, and various other deviations of the spine. He affirms, 
moreover, that he has established incontestably the dependence of this abnormal 
state of the muscular system upon the absence or disappearance more or less 
complete of corresponding portions of the central nervous systems. 

Breschet and Delpech maintained similar views, especially in relation to the 
dependence of the several varieties of club-foot upon some morbid condition of 
the cerebro-spinal axis. While Carnochan remarks as follows : " It appears 
most in accordance with science to refer the muscular spasmodic retraction, 
upon which congenital dislocations of the head of the femur from the cotyloid 
cavity depend, to a perverted condition of the excito-motor apparatus of the 
medulla spinalis, and more especially of that portion of it which is in direct 
relation with the reflex- motor nervous fibres, distributed to the pelvi-femoral 
muscles surrounding, and in connection with, the ilio-femoral articulation." 

Verneuil regards paralysis of one group of muscles as the direct cause ; in 
consequence of which the normal action of the opposing muscles tends to dis- 
place the bone ; whilst Reclus 2 applies the same theory to congenital dislocations 
of the femur. In effect, therefore, both Verneuil and Reclus refer the abnor- 
mities in question to the nervous centres. 

Palletta ascribes these deformities solely to an original defect of the germ ; 
and Dupuytren also declares that, in the case of a congenital dislocation of the 
hip, the causes are coeval with the earliest organization of the parts, and that 
the displacement is due rather to a defect in the depth or completeness of the 
acetabulum, than to accident or disease. 

Dollinger adopts essentially the same theory, attributing the imperfect forma- 
tion and shallowness of the cotyloid cavity to an arrest of development, and to 
a premature ossification of the Y-shaped cartilage which unites its three por- 
tions. Grawitz, also, recognizes arrest of development as the essential cause, 
but in the seven specimens he has examined he has not found premature ossifi- 
cation of the cartilage. 

Breschet and Delpech, both of whom, as I have already stated, refer them to 
some morbid condition of the cerebro-spinal axis, imagine that in consequence 
of this morbid condition of the nervous centres, there exists an arrest of de- 
velopment in the bones, muscles, ligaments, sockets, and, in short, through all 
the apparatus of the joint which is the seat of the deformity. 



1 Eoser, Arch. f. Klinik Chir., 1879, Bd. 28, HTt. 2. 

2 Eeclus, Kev. Mensuelle de Chir., 1878, p. 176. 



820 CONGENITAL DISLOCATIONS. 

After a full and careful consideration of this subject, I am prepared 
to admit the occasional agency of all the causes enumerated, and the 
probable concurrence of two or more in many instances ; nor do I see 
the propriety of rejecting, as Malgaigne has done, all that large class of 
malformations which seem to depend upon an arrest of development, or 
those which appear to be due mainly or solely to intra-uterine paralysis, 
of both of which many examples have been reported. 

As illustrating the relation which arrest of development sustains to this class 
of deformities, I may refer to the facts of hereditary transmission, and to the 
frequency with which other forms of imperfect development are associated with 
congenital dislocations. Cruveilhier 1 and Voss 2 have referred to examples in 
which the dislocations were accompanied with other malformations ; and Gra- 
witz found this coincidence in seven examples seen by him, while Pare, Palletta, 
Schreger, Dupuytren, Robert Bouvier, and Stromeyer have noted the marked 
influence of heredity. Kronlein mentions two infants, a brother and sister, in 
both of whom there existed a congenital dislocation of one hip ; and also the 
case of a boy, who was one of seven children, and whose grandmother presented 
the same malformation. 

§ 1. Congenital Dislocations of the Inferior Maxilla. 

Malgaigne says: "We know of no congenital dislocation of the jaw;" 
we are "not to accept the pretended dislocation observed by Guerin 
upon a derencephalous infant." The example recorded by Robert Smith 
he rejects also, declaring that he does " not comprehend how one can see 
in it a dislocation." For myself, I know of no reason why we should 
not take "seriously" the case mentioned by Guerin, since, so far as 
appears in his very brief report of the same, it might have been a true 
dislocation. The specimen was before the Academy, and if Malgaigne, 
from a personal examination, had become satisfied that a dislocation did 
not exist, he ought to have so informed us. But since he does not speak 
of having made it the subject of special examination, I shall feel com- 
pelled to accept of it as reported by Guerin. As to the objection offered 
to Mr. Smith's case, namely, that " aside of the complete absence of its 
history, the subject did not present the characteristic signs of dislocation, 
and the dissection , discovered neither maxillary condyle nor glenoid 
cavity," I must reply, the dissection seems to me to have furnished such 
evidence that the deformity was congenital as to render its history un- 
necessary ; the signs were characteristic, not indeed of a traumatic dislo- 
cation, but of a congenital dislocation, such as may be supposed to have 
been the result of an arrest of development, or of an original aberration 
of the germ. The following is a summary of the very complete account 
of this case given by Robert W. Smith (Fig. 501) : 

On the 5th of May, 1840, E. L., set. 38 years, an idiot from infancy, died at 
the Hardwick Hospital, in consequence of gangrene of the lungs. While making 
the autopsy, a singular deformity of the face was discovered. The right and 
left sides seemed as though they did not belong to the same individual, the 
left being in every respect more fully developed. Upon removing the integu- 
ments, the muscles of the right side were found to be much smaller than those 

i Cruveilhier, Trait, d 'an at. path., Atlas, liv. ii. pi. 2, fig. 23. 

2 Voss, Inversio Vesicae Urin., og lax. fein. con. hot samme individ., Christiania, 1857. 



CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 821 

of the left, and especially the masseter. These latter having been removed also, 
the condition of the right temporo-maxillary articulation was carefully studied. 
When the mouth was closed, the external lateral ligament, instead of being 
directed backward, was seen descending obliquely forward, to be attached to a 
very imperfectly developed condyle situated at least one-quarter of an inch in 
front of its natural position. There was neither an interarticular cartilage nor 
cartilage of incrustation, the joint surfaces being invested by a thick periosteum 
alone ; nor was there any distinct capsular ligament. Nearly the whole of the right 
side of the inferior maxilla was smaller than the left. The condyle was short 
and curved, being directed nearly horizontally inward, and resembling much more 



Fig. 501. 




R. W. Smith's ease of congenital dislocation of the inferior maxilla. 



the coracoid process than the condyle of the inferior maxilla. The coronoid 
process was very small and thin ; and the sigmoid notch could scarcely be said 
to exist. The articular eminence of the temporal bone was absent, there being 
in its place nearly a flat surface destitute of cartilage; which surface presented 
upon its inner side a shallow and semicircular sulcus where the hook-like con- 
dyle of the lower jaw had played. The malar, superior maxillary, and sphenoid 
bones of the right side had also suffered corresponding changes of form and 
relative size. The motions permitted in the lower jaw were more extensive than 
those which it enjoys in its normal condition, that is, upon the right side the 
ramus could be moved very freely forward and backward, while upon the 
left, the condyle underwent a species of rotation upon its axis. During life 
the patient was observed to be constantly performing this motion, and the 
right side of the face was continually affected with spasmodic twitches. When 
the mouth was closed, the front teeth of the upper jaw projected beyond those 



822 CONGENITAL DISLOCATIONS. 

of the lower, and when opened the deformity was in all respects greatly in- 
creased. 1 

Mr. Smith expresses his dissent from the views maintained by Ribes, 
namely, that the formation of the glenoid cavity is consequent upon the 
growth of the condyle, and that, were this process not formed, there 
would not exist either a glenoid cavity or an articular eminence. It is 
true that neither the glenoid cavity nor the articular eminence is found 
in the foetus. Until the seventh month of intra-uterine life there exists 
at this point of the temporal bone only a plane surface, and the glenoid 
cavity with its corresponding eminence is developed in proportion to the 
growth and development of the condyle. But Mr. Smith justly observes 
that although the development of the condyle does precede that of the 
glenoid cavity, " it by no means follows that the formation of the latter 
is due to the pressure of the former." The cavity, or rather the trans- 
verse eminence in front of the plane surface, does not exist in foetal life, 
because, owing to the peculiar form of the inferior maxilla at this period, 
its existence is not necessary. The vertical portion of the jaw (vertical 
only in the adult) is in the foetus nearly in the same line with the axis 
of the shaft, and consequently when the mouth is opened by the action 
of the muscles, the condyles are pressed upward and backward instead 
of upward and forward, as in the adult. A displacement forward cannot 
therefore very well occur ; and the protection of the articular eminences 
is not required. As age advances the angles of the jaw increase, the 
portions upon which the condyles rest become more vertical, and finally 
a displacement forward would occur whenever the mouth was well opened 
if the articular eminences were not present to afford a sufficient protec- 
tion in front. 

In the case of E. L. the fcetal condition of the bones upon one side remained 
during life, there being neither cavity nor eminence, and the condyle itself being 
only imperfectly developed; but the angle of the jaw had assumed the form 
which belongs to the adult, and the ascending ramus was vertical, consequently 
the condyle became somewhat displaced forward. 

Chronic rheumatic arthritis is occasionally found in the temporo-max- 
illary articulation of old persons ; and it may be important to distinguish 
it from congenital dislocation, with which, owing to the absorption of the 
articular eminence, and the consequent displacement of the condyle, it 
might possibly be confounded. 

Says Mr. Smith: " In a majority of instances, this remarkable disease attacks 
those of advanced age, and is symmetrical ; but occasionally it occurs during the 
period of adult life. In the latter case it is generally more rapid in its progress, 
is accompanied by greater pain, and is more liable to implicate the neck of the 
condyle, and the ramus of the jaw." 

When the condyle is implicated it becomes enlarged, and can be felt 
beneath the zygoma, in front of the meatus externus. The lymphatic 
glands of this region are sometimes enlarged, and the progress of the 
malady is attended with a constant but not generally severe pain. The 

1 Robert Smith, op. cit.,p. 283. 



CONGENITAL DISLOCATIONS OF THE SPINE. 823 

deformity of the face varies according as one or both articulations are 
affected. When the malady is confined to one joint, the chin is thrown 
slightly forward, but chiefly to the opposite side, and when both are 
implicated, the chin is simply advanced so that the teeth project beyond 
those of the upper jaw. As the disease progresses, the glenoid cavity 
enlarges by absorption, and at length a considerable portion of the whole 
of the articular eminence disappears and the jaw becomes gradually dis- 
placed through the action of the external pterygoids. The disease does 
not extend in the temporal bone beyond the articulating surface of the 
glenoid cavity. The condyle assumes a variety of forms, sometimes being 
greatly enlarged in all its diameters, while its upper surface may be flat- 
tened or conical. The articular cartilage disappears ; but Mr. Smith has 
never yet found any foreign bodies in the joint, and in only one instance 
have the surfaces been polished or eburnated as we often see in exam- 
ples of chronic rheumatic arthritis occurring in the hip, knee, and other 
joints. 

The following is an excellent summary of the diagnostic marks between 
congenital, accidental, and rheumatic dislocations, given by this writer : 

"1. In the congenital dislocation, the mouth can be freely opened 
and closed ; in chronic rheumatism, these motions can be performed, but 
not without uneasiness to the patient, an uneasiness which sometimes 
amounts to severe pain ; in dislocations from accident, the mouth cannot 
be closed. 

" 2. An involuntary flow of saliva accompanies the accidental dislo- 
cation alone, although in some cases of chronic rheumatism there is an 
increased secretion of that fluid. 

" 3. In congenital dislocation, the teeth of the upper jaw project 
beyond those of the lower ; the reverse is observed in accidental disloca- 
tion and in chronic rheumatism. 

" 4. In congenital dislocation there is no fulness in the cheek, such 
as the coronoid process produces in cases of accidental dislocation, and 
the condyle is not enlarged, as in some instances of chronic rheumatic 
arthritis."' 1 

§ 2. Congenital Dislocations of the Spine. 

Of the subluxation occipito-atloidean, Guerin gives : " First. Back- 
ward, an exaggerated flexion of the head upon the front of the neck 
and chest, with a commencement of sliding backward of the occipital 
condyles upon the articular facets of the atlas. Here are two examples 
in foetal anencephalous monsters. Second. Forward. Those who fol- 
low my consultations can recollect having seen last year an infant, about 
two or three months old, who offered a remarkable example. The head 
was exactly applied against the posterior part of the neck and upper 
part of the back. There was probably a sliding of the condyles forward, 
with elongation of the anterior ligaments." 2 The existence of the first 
of these varieties has since been denied by Guerin himself; 3 and it will 
be noticed that he only speaks of the second as a probable subluxation 

1 K. Smith, op. cit., p. 292. 

2 Guerin, op. cit., 1841, p. 29. 3 ibid., op. cit'., p. 32. 



824 CONGENITAL DISLOCATIONS. 

forward. Neither of them can, therefore, be regarded as established. 
Gu6rin further remarks that he has observed subluxations in the other 
regions of the spinal column many times ; and he showed to the Academy 
a foetus in which the spine presented, besides the occipito-atloidean dis- 
placement, a series of angular flexions in the antero-posterior direction, 
with sliding of the articular surfaces. 

In attempting to appreciate the value of Guerin 's observations upon 
this point, it must be remembered that he regards all cases of congenital 
torticollis, and other deviations of the spine, as examples of subluxation ; 
and, in some sense, I think the theory of this distinguished surgeon may 
be regarded as correct. The amount of articular displacement between 
each of the adjacent vertebrae may be very inconsiderable in any such 
case, yet, however trivial, if it exceeds the limits of natural motion, it 
may properly enough be regarded as the commencement of a dislocation. 

§ 3. Congenital Dislocations of the Pelvic Bones. 

Bassius speaks of a diastasis of the sacro-iliac symphysis in newly- 
born children, and infants ; but, according to Malgaigne, his account 
of these cases is not such as to warrant any conclusions as to the true 
nature of the displacements. 

Congenital exstrophy of the bladder is accompanied always with a 
deficiency of the central and upper portions of the pubic bones, the result 
manifestly of an arrest of development ; but these cases, of which I have 
seen several examples, are not properly examples of congenital disloca- 
tions, but only of diastases, the separated portions remaining in their 
normal position with reference to each other, except that they are not 
prolonged sufficiently to meet in the median line. 

Guerin declares, however, that he has seen congenital displacement, 
or overriding of the iliac bone upon the sacrum, accompanied with coxo- 
femoral dislocation and curvature of the spine. The same writer men- 
tions an example, in a foetal monster, of diastasis of the pubic. bones and 
of the sacro-iliac symphysis, accompanied with a turning out of the pubes 
upon the external face of the ischium. 1 

§ 4. Congenital Dislocations of the Sternum. 

Seger alone has reported one example of dislocation of the xiphoid 
cartilage from the sternum. 

A woman in the fifth month of pregnancy fell and dislocated her shoulder. 
Just four months after this she was brought to bed with an infant, well formed, 
except that, soon after it was born, the ensiform cartilage was observed to be 
remarkably movable, especially when the child hiccoughed, to which it was very 
subject. The cartilage was separated from the sternum by the breadth of the 
little finger. No treatment was employed ; the cartilage gradually became 
restored to its place, and in about one year it was firmly united to the sternum.' 5 

1 Guerin, Gaz. Med., 1851, p. 227. 

2 Seger, Epkem. Nat. Curios., 1677, from Malg., op. cit., p. 410. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 825 



§ 5. Congenital Dislocations of the Clavicle. 

Malgaigne says that a congenital dislocation at the sterno-clavicular 
articulation has never been observed ; but Guerin declares that he has 
established the existence of three varieties, namely : 

1. A dislocation of the sternal end of the clavicle inward and forward ; 
this extremity of the clavicle lying in front of the sternal fourchette. In 
illustration of which he presented to the Academy a plaster cast of a girl 
eight years old, in whom the displacement existed upon both sides. 

2. Inward and upward. Observed by him in a girl eight years old ; 
but which displacement took place only when the arm was moved, and 
through the contraction of the sterno-cleido-mastoideus muscle. 

3. Backward. Of which he presented two examples in the correspond- 
ing sides of a foetal monster. 

Shaw 1 reports a case of congenital dislocation of the sternal end of the clavicle 
upward in a girl two and a half years old. 

I have already referred to Fergusson's case of dislocation of the sternal end of 
the clavicle forward, which occurred during birth. The end rested in front of 
the sternum, and could be pushed into its place with great ease; but when left 
alone it immediately slipped out again. Nothing was done ; a new joint formed, 
and the child afterward possessed as much power in the one arm as in the 
other. 2 

Nadaud 3 also met with a dislocation of the sternal end forward in a newly-born 
child which had been delivered rapidly by the breech. The arm was immobil- 
ized by a sling, and the cure took place without deformity. 

Guerin says that he has seen a dislocation upward and outward at the acromial 
end of the clavicle in a foetus of three months. And I have mentioned, in the 
chapter on Traumatic Dislocations of the Bones, one case seen by me at the end 
of the fourth week of life. 

In regard to the treatment of either of these displacements of the 
clavicle, I need only remark that a reduction ought to be attempted ; 
and, if practicable, without much confinement to the little patient, it 
should be maintained until the bones have become fixed in their natural 
positions. It is quite probable that this can never be accomplished, at 
least perfectly ; but it will nevertheless be proper always to make the 
attempt. 

§ 6. Congenital Dislocations of the Shoulder. 

Guerin affirms that he has established the existence of three varieties 
of congenital scapulo-humeral dislocations, namely : 

1. Dislocations of the head of the humerus downward; of which 
variety he presented to the Academy a plaster cast taken from a boy ten 
years old. The displacement existed in both arms, but was much more 
pronounced in the right than in the left arm. It was due wholly to paral- 
ysis of the muscles about the joint, and to elongation of the capsule. 

1 Shaw, New York Med. Becord, Aug. 18,- Virehow und Hirsch's Jahresbericht fur 1877, 
p. 338. 

2 Fergusson, System of Surg., 4th Amer. ed., 1853, p. 203. 

3 Nadaud, Bordeaux Medical, 1874, No. 42. 



826 CONGENITAL DISLOCATIONS. 

2. Downward and inward; complete upon one side and incomplete upon 
the other, in the same person. The head of each humerus was applied 
against the ribs, and the arms maintained in an abduction almost hori- 
zontal, under the influence of the retraction of the deltoid muscles. 
" The same case," Guerin remarks, "has been confirmed by Roux." 

3. Subluxation upward and outward; seen on both sides in a foetal 
monster, which was offered to the Academy for examination ; and in one 
arm of a youth fifteen years old, of which Guerin presented a plaster 
cast. " It is characterized by a sliding of the head of the humerus in 
the direction indicated ; this sliding being favored by a corresponding 
displacement of the coracoid and acromion processes." 1 

Malgaigne, who regards " all luxations in consequence of paralysis as essen- 
tially posterior to birth," will not admit the first example mentioned by Guerin ; 
but, as I stated before, the objections made by Malgaigne have failed to convince 
me of the propriety of rejecting all of this class of reported examples. Of the 
second case, mentioned by Guerin as having been confirmed by Roux, Malgaigne 
declares that he has consulted Roux upon this matter, and that he affirms that 
" he has never seen a congenital luxation of the shoulder." 

Robert Smith has met with but two of the forms of congenital dislocation of 
the humerus described by Guerin, namely, that in which the head of the 
humerus is displaced forward, and that in which it is displaced backward. Of 
the first variety he has seen several examples. 

The first was in the person of A. S., set. 29 years, who presented both a 
dislocation of the head of the humerus under the coracoid process of the left 
scapula, and pes equinus in the foot of the left leg. The muscles of the arm 
and shoulder upon that side were feeble and greatly atrophied. The humerus 
was shortened ; its head being of the natural size and form, but when the arm 
hung by the side it dropped so far from its socket as to permit the thumb to be 
placed between the head and the acromion process. By pressing the humerus 
forward, the finger could be placed in the outer part of the glenoid cavity ; and 
although the head could be moved about thus freely, it seemed naturally to 
occupy only the anterior half of the glenoid fossa. 

Robert Smith's second example of subcoracoid congenital dislocation was 
presented in the person of Mr. H., set. 20, the condition of whose left shoulder 
resembled almost precisely that of Mr. S. "The deformity had existed from 
his birth, but became much more obvious and striking as he increased in age 
and stature." 

In the third example the child had attained nearly the age of one year before 
the condition of the limb attracted attention, which was then excited, not by 
the deformity of the shoulder, but by the atrophied condition of the muscles of 
the arm. The child had never complained of pain about the joint, nor had he 
ever met with any accident. No doubt this was also an example of paralysis, 
and it is not improbable that it was congenital, but the evidence upon this point 
is not very conclusive. When seen by Mr. Smith, he was nine years old, the 
shoulder and arm presenting the same appearance as in the other cases men- 
tioned. 

The fourth was also subcoracoid and symmetrical, the same deformity existing 
in both shoulders. This was in the person of a female, set. 21, who had been 
for many years a patient in a lunatic asylum, and who died of chronic inflam- 
mation of the meninges of the brain. Mr. Smith, who himself made the 
autopsy, first noticed the condition of the left shoulder. The muscles were 
atrophied ; the head of the humerus could be felt lying under the coracoid pro- 
cess ; the elbow projected from the side, but could be readily brought into con- 
tact with it. The right shoulder presented the same appearance, but the 
deformity was somewhat less, and the head of the humerus was not so directly 
underneath the coracoid process. From the external appearances presented by 

1 Guerin, op. cit., p. 30. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 827 

Fig. 502. Fig. 503. 





Double congenital subcoracoid dislocation; left 
scapula. (R. W. Smith.) 



Left humerus of same case. 

the two shoulders, Mr. Smith did not 
; : x doubt that these deviations from the 

natural state of the parts were not the 
result of violence. Proceeding to re- 
move the soft parts upon the left side, 
scarcely any trace was found of a 
glenoid cavity in its natural situation, 
but immediately underneath the cora- 
coid process, upon the costal surface 
of the scapula, was formed an oblong 
socket completely surrounded by a 
capsular ligament, which ligament included also that small portion of the 
original socket which remained. The head of the humerus was changed in 
form, being oval, and fitted, in some measure, to both the old and new sockets, 
upon which it seemed to rest alternately. Upon the right side, although the 
condition of the bones was somewhat different, the characteristic features of the 
deformity were similar (Figs. 502, 503). 

Malgaigne, who quotes Mr. Smith as saying that these dislocations must have 
been congenital, and for no other reason than because they were symmetrical, 
has scarcely done this author justice. Says Mr. Smith : " The position of the 
glenoid cavity, the remarkable form of the head of the humerus, the presence 
of a perfect glenoid ligament, the absence of any trace of disease, and the ex- 
istence of the deformity upon each side, all indicate the original nature of the 
malformation." 

The only example of backward dislocation seen by Mr. Smith was also sym- 
metrical, and seems to be equally well authenticated. This was in the person 
of a woman named Doyle, aet. 42, a lunatic also, who died February 8, 1839, in 
Dublin. She had been a patient in the lunatic asylum fifteen years, and was 
subject to severe epileptic convulsions, which ultimately proved fatal. Mr. 
Smith made the autopsy on the day following her death. The convolutions of 
the brain were small and atrophied, as is frequently observed in idiots. The two 
shoulders resembled each other so perfectly, both in external appearance and 
in their anatomy, that Mr. Smith has only found it necessary to describe par- 
ticularly the condition of one. The coracoid process was remarkably promi- 
nent, but the acromion was not so prominent as in accidental dislocations of the 
shoulder. The head of the humerus could be seen and felt distinctly moving 
with the shaft, upon the dorsal surface of the scapula. On removing the integu- 
ments, muscles, etc., no trace of a glenoid cavity was found in its natural situa- 
tion ; but upon the external surface of the neck of the scapula was a well- 
formed socket, which received the head of the humerus. This socket was 
covered with a cartilage of incrustation, and surrounded by a perfect capsule. 
The tendon of the biceps arose from the top and internal margin of the socket. 



828 



CONGENITAL DISLOCATIONS, 



The form of the acromion process was changed ; the capsule smaller than 
natural ; the head of the humerus irregularly oval, its anterior half alone being 
in contact with the glenoid cavity ; the great tubercle natural, but the lesser was 
elongated and curved, forming a process of an inch in length, around the base 
of which the tendon of the biceps muscle played 1 (Figs. 504, 505). 



Fig. 504. 



Fig. 505. 





R. W. Smith's case of double congenital backward 
dislocation. 



Right humerus of the same 
case. 



Gaillard 2 relates the case of a female child whose left arm was discovered to 
be deformed a few days after birth, and the elbow separated from the side. 
Later, the arm was found to be nearly immovable, and only at the end of four 
years was the dislocation recognized; but no attempt at reduction was then 
made. When sixteen years old, she was seen by Gaillard, who found the head 
of the humerus in the infraspinous fossa. The scapula, clavicle, and arm were 
preternaturally small ; the forearm, although well developed, could not be com- 
pletely extended nor supinated. Despite these unfavorable circumstances, 
Gaillard determined to make an attempt to accomplish the reduction. Four 
times in the space of eight days he submitted the arms to extension made at 
right angles with the body, by means of sixteen-pound weights, the extension 
being continued from twenty to twenty-five minutes, and occasionally his own 
exertions being added to the weights. On the fourth attempt the head of the 
bone was drawn gradually forward, and by a rotary motion it was finally made 
to slip into its socket ; but became immediately displaced. The next day 
Gaillard reduced it anew, and retained it in place one hour. Six days later it 
was again reduced, and, by the aid of bandages, permanently retained in place. 
The slight pain and swelling which followed soon disappeared ; and, by the aid 
of careful exercise, at the end of two years the arm had increased in length, 
and the patient could use the arm and hand so much better than before, as to 
encourage a hope that the recovery would be complete. 



1 Robert W. Smith, op. cit., p. 266. 

2 Gaillard, Mem. de l'Acad. de Med., 1841, from Malgaigne, p. 569. 



DISLOCATIONS OF RADIUS AND ULNA BACKWARD. 829 

Aristide Rodrigue, 1 of Holidaysburg, Penna., gives the following brief account 
of a case of intra-uterine dislocation of the shoulder, complicated with a frac- 
ture of the forearm : " The woman, when about four months gone with child, 
fell on her left side, striking a board, and felt herself much hurt at the time; at 
the full period she was delivered of a full-grown large boy with the following 
deformity, dislocation of the humerus into the axilla; fracture of both bones 
of the forearm of left side, lower third. Dislocation could not be reduced; 
union of the bones of the forearm by ossific matter complete ; bones passing 
each other, and hand at an angle of about 40°; the child did well otherwise; 
now, four years old, strong and healthy ; humerus has grown nearly apace with 
the other; forearm has not, and remains short and deformed as at birth ; the 
hand is of the same size with that of the sound side." 2 

I was asked to examine the arm of J. H., aet. 7 years, May 12, 1878, who 
had a subspinous dislocation of the left humerus. The parents stated that the 
birth of the child was premature, and that he was delivered with forceps, and 
as a head presentation. On the following day a swelling was noticed over the 
shoulder. On examination I found the head of the humerus resting upon the 
dorsum of the scapula below the spine. The scapula is smaller than the oppo- 
site scapula, and the arm is one and a half inches shorter than the other. The 
coracoid process is very prominent, and the humerus somewhat rotated inward. 
He uses the arm nearly as well as the other, and in this respect it is yearly im- 
proving. It is difficult to say positively whether this was strictly a congenital 
displacement, or whether it was caused by some violence employed in the act of 
delivery. Jenni 3 has recorded an example of congenital dislocation into the 
axilla of the left arm in a girl six years old. The child at birth occupied a 
position across the pelvis, demanding the intervention of the accoucheur. 
From the time of birth the arm hung inert beside the body. Both the left arm 
and forearm were somewhat smaller in diameter and shorter than the same por- 
tions of the right. Jenni reduced the dislocation ten times in succession, but it 
was as often reproduced. He then applied a plaster dressing, and left it on 
fifteen weeks, when he substituted a roller bandage, which was permitted to re- 
main some time, after which the dislocation was not reproduced. 

Kiister, 4 in a case of double congenital dislocation seen in a child one year 
old, and whose arms were seriously maimed in consequence, proposed to open 
the articulation and restore the bone to place. We are not informed whether 
he carried his intention into effect. 

§ 7. Congenital Dislocations of the Radius and Ulna Backward. 

It is not uncommon to meet with a slight subluxation backward of 
these bones in feeble and newly-born infants ; which condition is prob- 
ably due to a relaxation and elongation of the capsule. It is charac- 
terized by a preternatural mobility of the joint, and especially by the 
circumstance that the limb is capable of abnormal extension, or flexion 
backward, as it is sometimes called. Guerin has seen this condition 
more advanced, the bones of the forearm having actually overlapped 
somewhat upon the lower end of the humerus, so that the articular 
surface of this latter presented itself in the fold of the elbow. This was 
especially observed in a girl of 14 and a boy of 13 years, and also in the 
two arms of a foetal monster. 5 

Chaussier relates that a young woman, at the commencement of the ninth 
month of pregnancy, perceived suddenly movements of the fcetus so violent that 

1 Amer. Journ. Med. Sci. 

2 Rodrique, loc. cit:, Jan. 1854, p. 272. 

3 Jenni, Corresp. Blatt fiir Schweiz. Aerzte, No. 19, p. 580, ler, Oct. 1879. 

4 Klister, Berliner klin. Wochenschrift, No. 1, p. 9. 6 janv. 1879. 

5 Guerin, op. cit., p. 31. 



830 CONGENITAL DISLOCATIONS. 

she almost lost consciousness. These movements were repeated three times in 
the space of six miuutes, after which everything returned to its natural order, 
and the accouchement took place naturally and at the usual term. The infant 
was pale and feeble, and presented a complete backward dislocation of the radius 
and ulna. 1 

§ 8. Congenital Dislocations of the Head of the Radius. 

This dislocation has been reported by Dupuytren, Cruveilhier, Sandi- 
forte, Adams, Dubois, Verneuil, Deville, Robert Smith, Guerin, and 
Hayem, most of which were in the direction backward, some outward, 
but only one of them forward ; some were double, the same deformity 
being presented in both arms, and others were single. In a few exam- 
ples the dislocations were complicated with a consolidation of the radius 
to the ulna, and in others with a deficiency of the ulna or with some 
deformity indicating its congenital origin. Of the symmetrical or double 
dislocation backward Dupuytren furnishes the following example, pre- 
sented to him in 1830, by M. Loir : 

" The abnormal position which the head of either radius had assumed was at 
the back part of the lower extremity of the humerus, beyond which it extended 
for the space of at least an inch. This disposition of parts was absolutely iden- 
tical on the two sides, and had all the characters of a congenital affection." 2 

In January, 1866, J. F., set. 19, was admitted to the Bellevue Hospital, labor- 
ing under a general scrofulous cachexy, in whose person I found a congenital 
dislocation of the heads of both radii, outward. The dislocations are complete. 
The ulna are in place and of natural form, but their articulations at the wrist 
are loose. The remark applies to all other joints in the body. The power of 
pronation and supination is unimpaired, as well, also, as the power of flexion 
and extension. 

In the example of outward dislocation mentioned by Deville, there was an 
almost complete absence of the ulna, the head of the radius mounting upward 
more than three centimetres above the level of the articulation. 3 

Guerin, who has described an example of a .forward dislocation, says it was 
observed by him in a girl of 7 years, and that it was symmetrical. The two 
radii lay in front of the humeri, near the coronary fossettes.* Hayem 5 has also 
reported an example of double forward dislocation, which he believed to be 
congenital. 

§ 9. Congenital Dislocations of the Wrist. 

Guerin gives three forms of this dislocation. First, a dislocation 
forward, characterized by a sliding of the wrist before the bones of the 
forearm, and by the projection posteriorly of the low T er ends of the radius 
and ulna ; seen in an infant of six months, and in two adults. Second, 
backward and upward; seen in a child of six years, and accompanied 
with an incomplete paralysis of all the muscles of the forearm and hand. 
Third, backward and outward ; in a girl of 14 years, accompanied with 
incomplete paralysis. 6 Guerin has also seen three examples of disloca- 
tion outward in foetal monsters, and one of dislocation inward, as the 

1 Chaussier, from Malgaigne, op. cit., t. ii. p. 268. , 

2 Dupuytren, Injuries and Dis. of Bones, p. 117. 

3 Devilie, Bulletin de la Soc. Anat., p. 153. i Guerin, op. cit., p. 31. 
5 Hayem, Bull. Soc. Anat. de Paris, 1864, p. 56. 6 Guerin, p. 717. 



CONGENITAL DISLOCATIONS OF THE HIP. 831 

result of arrest of development. Robert Smith believes that the case of 
simple dislocation of the wrist or of the carpus forward, mentioned by 
Cruveilhier in his Anatomie Pathologique, was an example of congenital 
dislocation ; and he relates two other cases equally remarkable which 
came under his own observation. 

One was in the person of D. O'N., a lunatic and epileptic, who died when 36 
years old. Both upper extremities were deformed from birth ; the right pre- 
senting an example of dislocation of the carpus forward, and the left of disloca- 
tion of the carpus backward. The dissection showed that there had been an 
arrest of development, especially in the bones of the forearm and carpus. The 
second was in the person of a young woman who died of phthisis in the Rich- 
mond Hospital ; the right wrist presenting an example of congenital dislocation 
of the carpus forward from arrest of development also. 1 

Marrigues describes a very singular congenital displacement which he found 
upon a newly born infant. The radius and ulna were widely separated below, 
and in the interspace was lodged the whole of the first range of the carpal bones ; 
the hand being strongly turned inward. 2 

§ 10. Congenital Dislocations of the Fingers. 

Chaussier found in a foetus the last three fingers of the left hand dis- 
located at the metacarpo-phalangeal articulation. The thighs, knees, 
and feet were also dislocated. 3 

A. Berard speaks of an incurvation backward of the last two phalanges 
of the fingers as having been occasionally seen in newly born children of 
the female sex ; and Malgaigne adds that he has himself seen a woman 
who had, from birth, all the phalangettes carried backward to an angle 
of 135°, leaving the heads of the phalanges projecting forward under the 
skin. 4 

Robert has seen, in a girl 6 years old, a congenital lateral dislocation 
of the phalangette of the index finger, which was inclined outward at 
an obtuse angle. The external condyle of the lower extremity of the 
proximal phalanx was slightly atrophied, and the internal presented a 
corresponding projection. Robert cut the internal lateral ligament by a 
subcutaneous incision, but without any favorable result. 5 

§ 11. Congenital Dislocations of the Hip. 

Dupuytren thought that double dislocations of the hip-joint, as con- 
genital accidents, were more common than single dislocations, but in the 
experience of Pravaz the rule has been reversed, he having met with but 
four double dislocations in a total of nineteen. 

They have been noticed much oftener in females than in males. Of forty-five 
examples mentioned by Dupuytren and Pravaz, only seven or eight were males. 
The following table, constructed by Poinsot from statistics gathered by Drach- 
mann, Pravaz, and Kronlein, respectively, ought to be accepted as conclusive 

1 R. Smith, op. cit., pp. 238, 251. 

2 Marrigues, Malgaigne, from Journ. de Med., t. ii. p. 31, 1775. 

3 Chaussier, Malgaigne, op. cit., t. ii. p. 751. 

4 Berard, Malgaigne, op. cit., p. 773. 

5 Robert, from Malgaigne, op. cit., p. 773. 



i 



832 



CONGENITAL DISLOCATIONS. 



evidence that unilateral dislocations are more frequent than bilateral, and that 
these deformities are much more frequent in females than in males ; while as 
regards its occurrence in the right or left limb, no marked preference exists for 
either. 





Limits of 
observation. 


Males. 


Females 


Unilateral 






Observations. 


Left. 


Eight. 


9 


Bilateral. 


A. G. Draehmann (77) . . . 

Pravaz (107) 

Kronlein (90) 


1865-1880 
1863-1878 

1875-1880 


10 
11 

14 


67 
96 
76 


24 

27 
32 


24 
29 
22 


5 


29 
51 
31 






35 


239 


83 


75 


5 






274 


163 


111 



Congenital dislocations of the femur may be complete or incomplete. 
Of the complete dislocations, four varieties have been noticed. 

Upward and backward, upon the dorsum ilii. This variety is by far 
the most common. 

Upward and forward ; the head of the femur resting upon the emi- 
nentia ilio-pectinea. 

Downward and forward into the foramen thyroideum ; of which variety 
Chaussier alone mentions one example; but Delpech found in an infant, 
born paralytic, the head of the femur lodged habitually near the foramen 
thyroidum. 

Directly upward ; seen by Guerin, Pravaz, and others ; the head of 
the femur being placed immediately without the anterior inferior spinous 
process of the ilium. 

Guerin has observed, moreover, a single variety of subluxation ; char- 
acterized by the incomplete displacement of the head of the femur in the 
direction upward and backward, so that it rested upon the edge of the 
cotyloid cavity : " observed often in newly born children, and with those 
in whom the muscular dislocations are effected spontaneously after 
birth." 

In March, 1865, I saw a child who was born in 1860, with dislocation of both 
knees and both hip-joints. The legs at the time of birth were doubled forward 
upon the thighs, the heads of the tibias resting upon the front of the femurs, 
one inch above the condyles, the thighs being at right angles with the body and 
the feet touching the abdomen. The knees were drawn closely together. The 
dislocation of the heads of the femurs was not at this time recognized. By con- 
stant pressure Dr. Palmer had succeeded, at the end of one year, in restoring 
the legs to position, the thighs remaining flexed ; but when two years old she 
began to walk, with her body bent forward. The displacement of the hip-bones 
was then first discovered. When four years old the sartorius and tensor vaginae 
femoris were severed, but with very little benefit. At the time of my examina- 
tion she was five years old. The thighs were still flexed and adducted; by pres- 
sure upon the knees the femurs could be slid upward and backward upon the 
ilium one inch; on rotating the femurs the trochanters were observed to move 
upon a very short radius, indicating the entire absence of head and neck. She 
walked with the gait peculiar to these conditions. 

Both Delpech and Guerin have called attention to two varieties of what the 
latter terms pseudo-luxations ; of which the first simulates a dislocation upward 



CONGENITAL DISLOCATIONS OF THE HIP. 



83i 



and backward, and the second a dislocation downward and forward. In these 
examples, the extreme adduction or abduction of the thighs might lead to a 
belief that the bones were dislocated, when in fact the abnormal position of the 
limbs is due only to muscular contraction, without actual articular displacement. 

In the remarks which follow I shall have special reference to that form 
of congenital dislocations of the femur in which the head of the bone rests 
upon the dorsum ilii, as being that which will presented in a vast ma- 
jority of cases, and which, characterized by the same general phenomena, 
may be regarded as typical of all the others. 

Symptomatology. — First. When the dislocation is double. In these 
examples the deformity is often found to be absolutely symmetrical ; the 
opposite limbs being of precisely the same length, and in the same relative 
positions; a circumstances which, when it exists, may render the diagnosis 
more difficult, or may cause it to be for a long time entirely overlooked. 
It is in such cases especially that the deformity is not usually discovered 
until the child begins to walk. 



Fig. 506. 



Fig. 507. 





Singrle. 



Congenital dislocations of hip. 



Double. 



The first circumstance which would naturally arrest our attention, if 
the person who is the subject of this double dislocation is stripped and 
placed erect before us, is the great apparent length of the arms and of 
the body in comparison with the lower extremities. We may next observe 
that the great trochanters are carried upward and backward, so as to 
make a remarkable projection in this direction ; the lumbar portion of 
the spinal column is thrown very much forward and the dorsal portion 
backward. The thighs incline inward, so as almost to cross each other ; 
the whole of the lower extremities are imperfectly developed and feeble ; 

53 



834 CONGENITAL DISLOCATIONS. 

the toes are generally pointed directly forward, or they may be noticed 
to turn inward (Figs. 506, 507). 

When the person stands, and his limbs are not in motion, the heel is 
usually brought down fairly to the floor ; but in walking, and especially 
in the attempt to run, he touches only the balls and toes of his feet. 
"When they are about to walk," says Pravaz, "we see them lift them- 
selves upon the points of the feet, to incline the superior part of the trunk 
toward the member which is about to support the weight of the body, 
and to lift the other from the ground with an effort, in order to carry it 
forward. At this moment one of the trochanters, that which corresponds 
to the column of sustentation, appears to approach the iliac crest more 
nearly than when the patient is standing upon his two feet." In con- 
sequence of which mobility of the thigh-bones the patient assumes a 
peculiar waddling gait which is not only ungraceful, but exceedingly 
fatiguing. The difficulty of progression is, however, very variable in 
different persons. Sometimes the patient requires no aid whatever, and 
at other times he cannot walk without assistance. Generally it increases 
with age. It is especially deserving of notice that in rapid progression 
the mobility of the heads of the femurs is appreciably less than in slow 
progression, which is explained by the more constant and vigorous con- 
traction of the muscles about the joint, when the motions of the limb are 
rapid. In the recumbent posture, the thighs may be drawn down easily 
to almost their natural positions. The only exception to this rule, accord- 
ing to Carnochan, "is when the head of the femur has escaped from the 
natural capsule in which it was originally inclosed, and a new socket has 
been formed upon the dorsum of the ilium." Abduction is performed 
with difficulty ; adduction and rotation, especially inward, being less 
restricted. 

Second. When the dislocation is only upon one side. In these cases 
the symptoms are essentially the same as in the double dislocation ; with 
only such slight differences and peculiarities as would naturally suggest 
themselves to the surgeon, and which will not, therefore, demand special 
consideration. 

Pathology. — The head of the femur is sometimes merely changed in 
form and consistence, the neck also undergoing corresponding alterations 
in its size, form, direction, etc. ; at other times the head is absent alto- 
gether, and with it a considerable portion of the whole of the neck has 
disappeared. The pelvic bones are usually more or less deformed. The 
acetabulum may be entirely deficient, or it may present itself as an 
irregular bony protuberance, without cartilage, fibro-cartilage, or liga- 
ments. Sometimes it exists as an oval or triangular cavity, which is 
expanded at its superior and posterior margin into a distinct fossa, where 
the head of the femur, descending from the dorsum ilii, occasionally rests. 
A new cavity is formed usually upon the side of the pelvis, which is shal- 
low and without an elevated margin, or it may be deeper and more com- 
plete in its construction by the addition of an osseous border. In either 
case the new socket is often lined with a true periosteum and synovial 
membrane; but not unfrequently it is unprotected by any soft tissue, the 
surface being hard and polished like ivory. 

The head of the femur, having escaped from its original capsule, 



CONGENITAL DISLOCATIONS OF THE HIP. 835 

through a button-like opening, rests in this socket constantly. In still 
other examples the head of the femur remains within its capsule, and 
ma}^ be observed to play backward and forward between the two sockets ; 
or the head and neck being absorbed, and the capsule remaining entire, 
the latter is converted into a long, narrow sac, somewhat contracted in 
its centre ; or finally into a firm ligamentous cord, which being attached 
to the stunted upper extremity of the femur, limits its motions in the 
direction of the crest of the ilium. In this case no new socket is formed. 
A portion of the pelvi-femoral muscles are contracted, in consequence of 
an approximation of their points of origin and insertion, and remaining 
in a state of comparative, if not absolute, inertia, they become atrophied, 
or pass into a condition of fatty degeneration ; while other muscles, in 
consequence of the increased labor which they have to perform, become 
hypertrophied, or degenerate into a fibrous tissue. 

Treatment. — The treatment of this deformity has been the subject of 
much discussion from an early period, but as yet no definite method has 
been established. Dupuytren studied the treatment quite thoroughly, 
and his observations are important. He says : 

" When we call to mind the natural proneness which the heads of thigh-bones 
have to ascend to the external iliac fossae, and that this tendency is partly due 
to the superincumbent weight of the body, and in part to muscular action, a 
just conception may be formed of the indications on which the employment of 
palliative remedies should be founded. The object should be to relieve the 
lower limbs of the superincumbent weight on the one hand, and on the other to 
moderate the muscular action. Both of these indications are in part fulfilled 
by repose; and the attitude most conducive to this effect is the sitting posture, 
in which the weight of the upper part of the body is not transmitted to the 
lower extremities, but is centred in the tuberosities of the ischia. Therefore, 
laboring persons afflicted with this infirmity should be recommended to adopt 
a sedentary occupation, as a calling which requires much standing and walking 
about would dangerously aggravate their deformity. Yet one would scarcely 
be willing to condemn such individuals to perpetual repose; and to avoid this 
it is necessary to discover some means for diminishing the inconveniences which 
attend the upright posture, the act of walking and other exercises. Experience 
has taught me hitherto but two methods of obtaining this important object: the 
first consists in the daily employment of a perfectly cold bath, in which all the 
body should be immersed for the space of three or four minutes, the head being 
protected by an oiled-silk cap; the water maybe fresh or salt; and the only 
precautions necessary to take are to avoid bathing when the body is in a state 
of perspiration, or when the catamenial discharge is present. These baths have 
a local, as well as general, tonic effect. The second method consists in the con- 
stant use, at least during the day, of a belt, which embraces the pelvis, fitting 
closely over the great trochanters, and keeping them at a constant height, so as 
to bind the parts together, and prevent that continual unsteadiness of the body 
which results from the loose connections of the heads of the thigh-bones. For 
the proper fulfilment of these indications, certain precautions are necessary in 
the construction of this cincture; in the first place, it should occupy the narrow 
interval between the crest of the ilium and great trochanters, completely filling 
this space, and therefore being about three or four fingers' breadth, according 
to the age and size of the patient. It should further be well padded with wool 
or cotton, and covered with doeskin, so that it may not abrade the parts to which 
it is applied ; and there should be a piece let in on either side, so as to receive 
and support the trochanters without entirely covering them ; it should be 
buckled behind, and padded straps be carried under the thigh, and across the 
tuberosity of the ischium, on either side, to prevent the zone from slipping up. 
I do not mean to assert that I have ever succeeded in completely getting rid of 



836 CONGENITAL DISLOCATIONS. 

the inconveniences of congenital dislocations of the thigh-bones, but I have pre- 
vented their increasing, and have rendered supportable what I could not cure. 
The testimony of some patients to the value of this treatment has been of a most 
unequivocal character; for being worried by the pressure of the belt, they have 
laid it aside, but have speedily restored it again, as they found that without it 
they had neither a sense of firmness in the hip nor confidence in walking." 

In relation to which opinions the same excellent writer subsequently made 
the following candid admission: " I at first thought that no benefit would be 
derived in these cases from the employment of continual traction on the lower 
extremities, for reasons already stated ; but the experiments of MM. Lafond and 
Duval tend to throw some doubt on the correctness of this conclusion. These 
distinguished practitioners tested the influence of extension, in their orthopaedic 
institution, on a child eight or nine years of age, who was the subject of double 
congenital dislocation. of the hip; after the uninterrupted employment of this 
treatment for some weeks, I satisfied myself that the limbs had resumed their 
natural length and direction ; but I was not a little astonished to find that after 
extension had been persisted in for three or four months continuously, the 
greater part of the beneficial results remained for several weeks undiminished. 
It would be idle, it is true, to generalize on this single case; but as an isolated 
example of the utility of extension it is interesting, and it may be the forerunner 
of more important results." 1 

Since which time Humbert and Jacquier, who, as well as Duval and 
Lafond, confined themselves to the treatment of deformities, claim to have 
met with equal success in the management of these cases by extension 
alone; and, still more lately, Guerin, of Paris, and Pravaz, of Lyons, by 
the adoption of the same general principle more or less modified, have 
added new triumphs and greatly enlarged its application. Other sur- 
geons have confined their efforts to the reduction of the dislocation, and 
they have, consequently, abandoned all those cases in which, owing to 
the complete absence of the natural socket, or to 'the want of sufficient 
mobility in the limb, the reduction was deemed impossible ; but Guerin 
has gone a step farther, and has sought to establish a new socket upon 
some point of the pelvic bones as near as possible to its natural articular 



" The means which I adopt," says Guerin, "are based upon a recognition of 
the processes which nature employs for the attainment of the same purpose, and 
of which mine are but an imitation. I have shown that the essential condition 
of the formation of artificial cavities is perforation of the articular capsule, and 
the placing in contact of the luxated extremity with an osseous surface, and 
that the condition of the maintenance of this abnormal rapport is the intimate 
adherence of the borders of the rent with the circumference of the new cavity. 
Now it appeared to me that art could realize, in all points, the conditions which 
preside at the spontaneous formation of artificial joints. To this end I com- 
mence by practising under the skin, and at the point corresponding to that 
where it is most convenient to fix the luxated extremity, scarifications of the 
capsule, down to the bone to which it is attached. By this means the dislocated 
extremity is placed in immediate contact with the bony surface upon which it 
reposes. It makes upon this point a beginning of the work of organization 
resulting from the adhesion and fusion of the scarified points with the corre- 
sponding points of this surface. Then, in order to circumscribe and imprison 
the luxated extremity, in this place of election, I practise all about deep scarifi- 
cations, which tend to excite the same work of organization and to establish 
fibro-cellular adhesions between the incised borders of the capsule and the con- 
tiguous bony surfaces. Finally, when the fibro-cellular adhesions are supposed 
to be sufficiently solid to resist the movements of the new articulation, I pro- 

1 Dupuytren, op. cit.. pp. 176-178. 



CONGENITAL DISLOCATIONS OF THE PATELLA. 837 

voke, little by little, the development of the cavity destined to embrace the 
luxated extremity by the means which Nature herself employs in analogous 
circumstances ; that is to say, by circumscribed and frequent movements of this 
articulation." 1 

The treatment ought to be commenced as early as possible, no exam- 
ples of success having been recorded in persons over fifteen years of age; 
while the youngest child Avhose treatment is reported as successful was 
three years of age. For the purposes of making the requisite extension, 
and of maintaining the bone in place, Pravaz (who does not, however, 
adopt Guerin' s practice of establishing for the head of the bone a new 
socket, but only seeks to reduce and maintain it in its old socket) has 
invented several forms of apparatus adapted to the different stages of 
progress in the treatment. Heine, of Cannstaclt, Guerin, and others, 
have also suggested special contrivances for the same purpose ; but no 
surgeon who understands fully the principle upon which the cure is sup- 
posed to be accomplished, will be at loss for apparatus suitable for making 
the necessary extension, or for maintaining the reduction when once it 
has been eifected. 

The length of time required for the completion of a cure, where a cure 
is possible, must vary according to the age and health of the patient, 
and according to the pathological condition of the joint, and may be 
found to extend from a few months to one or more years. It is unne- 
cessary to say that where the accomplishment of the cure demands a 
period of several years, the treatment must be intermittent and greatly 
varied, so as to suit all the changing circumstances in the condition of 
the patient. 

Finally, if after a fair trial we fail to accomplish a cure, or if the con- 
dition of the child will not warrant even the attempt, we ought as far as 
possible to seek to prevent an increase of the deformity by such means as 
our ingenuity may suggest, or by such judicious appliances and general 
management as we have seen recommended by Dupuytren. 

South says that he has seen one case of double dislocation in which the walk- 
ing was at first extremely difficult, but from the fifteenth year and onward the 
patient so improved that at the twentieth year scarcely any trace of the peculiar 
gait could be discovered. 2 

[In addition to the methods of treatment above mentioned, resection has been 
successfully performed by Rose; Margary deepened the acetabulum by chisel- 
ling, and then replaced the head, but his patient died of pyaemia; Paoli deep- 
ened the cavity and diminished the size of the head with the effect of reducing 
the shortening by nine and a half centimetres. The most successful treatment 
recently instituted is that of Dr. Buckminster Brown, 3 of Boston, who kept up 
continuous traction for thirteen months with the effect of quite restoring the 
form and walk of the patient.] 

§ 12. Congenital Dislocations of the Patella. 

Palletta found a dislocation in the cadaver which he supposed to be 
congenital. 4 Michaelis has reported two cases ; one in a young man of 

1 Guerin, op. cit., pp. 81-83. 2 South, Note to Chelius, op. cit., vol. ii. p. 245. 

3 Brown, Boston Med. and Surg. Journ , June 4, 1885. 

4 Palletta, Exercitationes Pathologicae, p. 91. 



838 CONGENITAL DISLOCATIONS. 

seventeen years, and the other in a girl of fourteen, each of whom affirmed 
that it had existed from birth. 1 Both of these examples presented them- 
selves at the hospital on account of hydrarthrosis of the knee-joints, and 
Malgaigne, who had himself seen a similar case, is disposed to regard 
them all as examples of pathological rather than congenital dislocations. 
Periat reports a case in which the dislocation was only produced by 
walking, and in relation to the authenticity or pertinence of which Mal- 
gaigne seems also to entertain a doubt. 2 

South says that he has seen a congenital dislocation of both legs, in an aged 
man. The patellse rested entirely upon the outer faces of the external condyles, 
leaving the front of the knee-joint completely uncovered. When the limbs were 
extended the patellse could be easily made to resume their natural positions, 
but on the patient's making the slightest movement they were again displaced. 
The knees were very much inclined inward, the feet outward, and his gait was 
difficult and unsteady. 3 

Dr. Samuel G. Wolcott, of Utica, N. Y., informs me that he has under obser- 
vation a case similar to the one reported by South, in a healthy and otherwise 
well-formed and well-developed boy, set. 4. ''When the legs are flexed the 
patellse slip outward upon the external condyles of the femurs, and on extend- 
ing the legs the patellse resume their positions in front of the knee-joints. This 
occurs at every step he takes. The knees are strongly inward, and the feet out- 
ward. His step is very insecure, and if accidentally he hits his feet or legs 
against anything in walking, he invariably falls." 

The most remarkable example, however, has been reported by Dr. E. J. Cas- 
well, of Providence, R. L, inasmuch as no less than five members of the same 
family have double congenital dislocations of the patellse. The man who was 
the subject of Dr. Caswell's special examination is 43 years old, and possessed 
of a good constitution. The patellse lay upon the outer condyles, and are mov- 
able, performing their functions nearly as well as if placed in their proper 
positions. He walks without difficulty upon level ground, or upon an ascending 
plane, but great caution is required in descending. The right patella is longer 
and less movable than the left, and the muscles of both of his lower extremities 
are small. "In addition to his labor as an operative, he cultivates a small farm." 
Dr. Caswell examined his son and found the same malposition, but less marked 
than in the case of the father. The father then stated that his own father, his 
sister, and the son of his half-brother by the same father, had a similar de- 
formity. 4 

Servier 5 relates a case of congenital dislocation of the patella associated with 
other deformities, and both the father and the brother had dislocations of the 
patella. Zielewicz 6 has collected eight cases of congenital outward dislocation. 
To these examples P. Berger 7 has added three others. Holthouse 8 mentions a 
case seen by himself, and Lannelongue 9 reports a similar case. 

§ 13. Congenital Dislocations of the Knee. 

The head of the tibia has been found, at birth, dislocated forward, 
backward, inward, outward, inward and backward, outward and back- 
ward, and simply rotated inward. Most of these dislocations were in- 

1 Michaelis, Rev. Med. Chirurg., torn. xv. p. 65. 

2 Periat, Malgaigne, op. cit., torn. ii. p. 932. 

3 South, Note to Chelius, op. cit., vol. ii. p. 247. 
* Caswell, Araer. Journ. Med. Sei., July, 1865. 

6 Servier, Gaz. Hebd. de Med. et de Chir., Avril 5, 1872. 

6 Zielewicz, Berliner klin. Wochens. t. 6, p. 25, 1869. 

T P. Berger, Art. Rotule, Diet. Enc. Sc. Med., 3d ser., t. 5, p. 360. 

8 Holthouse, The Lancet, Aug. 24, 1872, vol. ii. p. 258. 

9 Lannelongue, Bull. Soc. de Chir. de Paris, 1880, p. 236. 






CONGENITAL DISLOCATIONS OF THE KNEE. 839 

complete ; and of them all, the dislocation forward has been observed 
much the most often. A subluxation forward of the head of the tibia 
has been seen by Guerin in a foetal monster, accompanied with extreme 
retraction of the extensor muscles of the leg. 1 Cruveilhier has dissected 
a foetus affected with a similar subluxation. 2 In these examples the 
displacement forward at the articular surface was but slight, and the 
anterior flexion of the limb inconsiderable ; but when the dislocation is 
complete, or nearly so, the deformity is in all respects very much 
increased ; as the following examples will illustrate. 

Dr. D. H. Bard, of Troy, Vermont, has reported an example of complete ante- 
rior dislocation of the tibia, seen by himself, in a newborn infant. The leg was 
found drawn forward upon the thigh at an acute angle, so that the toes pointed 
toward the face of the child, and the bottom of the foot was directed forward. 
By the application of moderate force, the limb could be straightened and even 
flexed completely. These motions inflicted no pain. It was especially noticed 
that in bringing down the leg from its position of extreme anterior flexion (ex- 
tension) more force was required in the first part of the manoeuvre than in the 
last; and that if, having brought the leg down, it was left to itself, it imme- 
diately resumed the abnormal position, moving at first slowly, but after a time 
much more rapidly. The limb was confined by bandages for a short time, and 
it did not afterward show any disposition to return to its unnatural position. 
The child did well, and when it began to use its legs, no difference could be dis- 
covered between them. 3 

J. Youmans, of Portageville, N. Y., reports a similar case which occurred in 
his own practice. A healthy woman was delivered, on the 16th of August, 1859, 
of a full-grown female child, whose left knee was so completely dislocated that 
the toes rested upon the anterior part of the thigh near the groin. Dr. You- 
mans immediately took hold of the limb and brought it to its natural form, but 
as soon as he relinquished his hold, it flew back to its original position. Having 
again straightened the leg it was retained in place easily by two pieces of whale- 
bone tied upon each side of the thigh and body. Some soreness and swelling 
ensued, and it was some weeks before the splint could be safely removed. At 
the time of the report, October 11, 1860, the child was using the limb with as 
much freedom and dexterity as other children of her own age. In the report 
particular attention is called to the disposition on the part of the limb to resume 
its unnatural position with a spring, showing contraction of the anterior muscles 
of the thigh ; to the fact that the patella of this knee was smaller than the other, 
and that the skin on the front of the knee was wrinkled as it is usually back of 
the knee in fat children. 4 

I have mentioned a case of congenital forward dislocation of both tibiae which 
came under my observation, in the section on congenital dislocations of the hip, 
and I have recently seen a case of congenital subluxation of both tibiae back- 
ward, occasioned by contraction of the hamstrings. Section of the muscles 
restored the bones nearly to their normal position. 

Chatelain was consulted in relation to a similar case, in which the restoration 
of the limb to its natural position was also easily effected, and by means of three 
metallic splints, applied during about fifteen days, the cure was consummated. 
Chatelain directed, however, that the leg should be kept flexed upon the thigh 
eight days longer. 5 

Kleeberg found a child with the leg so much flexed forward (extended) upon 
the thigh that the popliteal region became the lowest point of the limb ; in front 
and above the articular extremity of the tibia could be felt, and the condyles of 

1 Guerin, op. cit., p. 33. 

2 Cruveilhier, Atlas de l'Anat. Patholog., 2e livr., pi. 2. 

3 Bard, Amer. Journ. Med. Sci., Feb. 1835, p. 555, from Boston Med. and Surg. Journ., 
Nov. 26, 1834. 

4 Youmans, Boston Med. and Surg. Journ., Oct. 25, I860, vol. lxiii. p. 250. 

5 Chatelain, Bibliotheque Med., torn. lxxv. p. 85. 



840 CONGENITAL DISLOCATIONS. 

the femur made a corresponding projection behind into the popliteal space. This 
was plainly an example of complete dislocation ; and, contrary to what was 
observed in Bard's case, flexion of the limb backward was difficult and painful. 
The treatment was commenced by securing the limb in a straight position by 
means of a splint and roller; subsequently, Kleeberg carried the limb back to 
an obtuse angle, and finally, it was kept eight days in a position of extreme 
flexion. A complete cure was said to have been accomplished in about two 
weeks. 1 

Richardson and Porter 2 report a case of congenital dislocation of the tibia for- 
ward, in which the leg was carried to a right angle with the thigh. Reduction 
was easily effected and maintained by a roller. The cure was effected in about 
fourteen days. They report also another case, in which the anterior hyperex- 
tension was such that the leg could be laid upon the thigh. The cure was effected 
in ten weeks by the same means. 

Bertin 3 found a child at birth with a displacement similar to the second exam- 
ple seen by Richardson and Porter, and in whom, under the use of massage and 
bandaging, all traces of the deformity disappeared in fifteen days. At the end of 
seven years the cure remained complete. 

In a case seen by Motte, 4 where the heel touched the corresponding shoulder, 
the leg turned on its axis, the reduction was easily effected, and being main- 
tained by a bandage, the cure was effected in about fifteen days. After three 
years no traces of the deformity existed, and the functions of the limb were per- 
fectly restored. 

Moos 5 saw in a child two and a half years old, a congenital displacement, in 
which the leg was extended forward to a right angle with the thigh. The dis- 
location had been reduced when the child was six weeks old, but in spite of an 
apparatus continuously applied, there still continued a tendency to subluxation 
forward, the knee inclined backward and the foot was everted. 

Gueniot 6 communicated to the Surgical Society of Paris two examples of con- 
genital incomplete forward dislocation of the tibia. In both cases a cure was 
speedily effected by very simple means. At the same seance Gueniot presented 
a case observed by Perier, almost precisely analogous with those seen by him- 
self, but in which case, in spite of apparatus, the deformity persisted at the end 
of about six weeks, and without manifest improvement. 

Guerin has seen a subluxation backward, accompanied with a slight rotation 
of the head of the tibia outward, in a girl fourteen years old ; and which, he 
affirms, was congenital, characterized by a permanent flexion (backward) of the 
leg upon the thijrh, and a sliding of the condyles of the tibia backward. This 
girl was under Guerin's treatment, but with what result is not stated. 7 Chaussier 
found both tibia? displaced backward in an infant otherwise deformed. 8 Robert 
speaks of an example of lateral subluxation in a man, which had existed from 
birth. The right knee was thrown inward, and the left outward. 9 Guerin 
"operated '' publicly upon a child, two years old, who had a congenital disloca- 
tion of the head of the tibia backward and inward, accompanied with a slight 
rotation of the leg inward. 10 In what manner he operated, and with what result, 
he does not inform us. The same writer speaks of a subluxation backward and 
outward, with rotation in the same direction, a deformity which, he affirms, is 
very frequent, and which appears especially after birth, although the causes 
which produce it have given their first impulse during intra-uterine life. The 
case quoted from Robert, by Malgaigne, as an example of dislocation inward, 
seems to have been rather a case of semi-rotation of the articular surfaces, the 
inner condyle being thrown back into the popliteal space, while the outer con- 
dyle still retained its natural position. 

1 Kleeberg, Malgaigne, op. cit., p. 983. 

2 Richardson and Porter, Boston Med. and Surg. Journ., Sept. 3 6, 1875'. 

3 Bertin, Union Med , 14 Oct., 1880. 

4 Motte, Ball. Acad. Royale de Belgique, 3d Ser., t. 10, No. 2. 

5 Moos, Archiv fur klin. Chir., Bd. 17, Hft. 3, p. 492. 

6 Gueniot and Perier, Bull. Soe. de Chir. de Paris, 1880, pp 442-683. 

7 Guerin, sur les Lux. Congen, p. 33. 

8 Chaussier, Malgaigne, op. cit., p, 884. 

9 Robert, Malgaigne, op. cit., p. 985. 
10 Guerin, sur les Lux. Congen., p. 33. 



CONGENITAL DISLOCATIONS OF THE TOES. 841 



§ 14. Congenital Dislocations of the Tarsal Bones. 

Under this general term may be included all those varieties of sub- 
luxation of the several bones which compose the tarsus, and which are 
known as examples of talipes or club-foot ; such as tibio-astragaloicl dis- 
locations, astragalo-scaphoid, calcaneo-astragaloid, calcaneo-cuboid, etc. 

Although these deformities may properly enough claim a place in a 
chapter on congenital dislocations, they have so long been the subjects 
of special treatises as to justify their exclusion from the present volume. 

§ 15. Congenital Dislocations of the Toes. 

Observed occasionally at the metatarso-phalangeal articulations ; the 
articular facets of the first phalanges suffering a subluxation upward, or 
laterally upon the corresponding metatarsal bones. 

Guerin has noticed especially a congenital lateral subluxation of the 
great toe. 1 

1 Guerin, op. cit., p. 34. 



INDEX 



PART I. FRACTURES 



ABSCESS of the sternum, 165 
Acetabulum, 343 
Acromion process, 199 
Allis, carrying function of humerus, 257 

treatment fractures of condyles, 258 

relaxation of fascia, 374 
Amesbury's thigh splint, 389 
Anaesthetics, use of, in diagnosis, 44 
Anaplasty in fractures of the septum na- 

rium, 101 
Anatomical neck of humerus, 207 
Anchor splint, 121 
Ankylosis after Colles's fracture, 284 

after fractures of elbow, 262 

after fracture of patella, 440 

of knee, 524 
Apparatus immobile, 66 
Arteries, ruptured, 73 
Arthritis, chronic, 365 
Arytenoid cartilages, fractures of, 139 
Astragalus, 491 
Asymmetry of long bones, 388 
Atlas, 159 
Atrophy, 37 

surgical neck of humerus, 219 

neck of femur, intracapsular, 355 

tibia above tubercle, 459 
Axis, 156 

and atlas, 160 



BADLY united fracture of radius, 263 
Barton's bandage, 126 
fracture, 279 
Base of acetabulum, 343 

of condyles of femur, 419 
of condyles of humerus, 237 
Bauer's wire splints, 486 
Bavarian splint, 480 
Bean, lower jaw apparatus, 123 
Bending of bones, 83 
Bigelow, stellate fracture of radius, 275 

rim of acetabulum, 349 
Body of the scapula, 194 

odies of the vertebrae, 147 
Bond's elbow splint, 243 

radius splint, 287 
Bones, repair of, 46 
badly united, 73 
delayed union, 74 



i Bones, fibrous union, 74 
non-union, 74 
Boyer's thigh splint, 390 
Brainard, perforator, 81 
: Bryant, ilio-femoral triangle, 387 

Brown, anchor splint, 121 
! Buck, lower jaw, 119 
thigh splint, 394 



riALCAXEUM, 493 
\J Carpal bones, 329 
Cartilages of the ribs, 171 
| Cervical vertebrae, bodies of five lower, 
151 
axis, 156 
atlas, 159 
atlas and axis, 160 
Children, fracture of femur, 415 
Chronic rheumatic arthritis, 365 
Clavicle, 173 

immediate dressing, 58 
partial fractures, 193 
dressing for children, 193 
Cline, trephining vertebrae, 145 

fracture of atlas, 159 
Coccyx, 351 
Colles's fracture, 271 

double, 271 
Comminuted fracture, 72 
Common signs of fracture, 42 
Compound fractures, 72 
forearm, 328 
thigh, 418 
patella, 457 
Condyles of humerus, 247 
internal, 255 
external, 259 
base, 237 

base and between condyles, 244 
of femur, 422 
external, 422 
internal, 424 
occiput, 140 
base, 419 

between condyles, 425 
Congenital, 39, 227, 458 
Coracoid process, 203 
Condyle of occiput, 140 
Coronoid process of ulna, 310 



i 



844 



INDEX. 



Cotyloid cavity, 343 

Crandall, extension, fracture of leg, 484 

Cricoid cartilage, 140 

Crosby, femur, external condyle, 422 



DANIELS'S fracture-bed, 408 
Deformities of legs, 490 
correcting, 470 
Delayed or non-union, 74 
Denticulated fractures, 36 
Dextrine, 67 
Diagnosis, general, 41 
Dislocation of humerus, diagnosis, 220 
Displacements, varieties, 44 
Dorsal vertebrae, 151 
Dressing, immediate, 56 
Drill, Brainard's, 81 

Dieffenbach's, 80 
Drilling in non-union, 80 
Dugas, dislocation of humerus, 220 



ELBOW splint, Physick's, 242 
immediate care, 58 

Kirkbride's, 242 

Eose's, 242 

Welch's, 242 

Bond's, 242 

the author's, 243 
Embolism, venous and fatty, 55 
Emphysema in fracture of ribs, 171 
Epicondyle of humerus, external, 254 

internal, 247 
Epiphyseal separations, 37 

acromion, 200 

humerus, upper end, 213 
lower end, 238 

olecranon process, 310 

femur, upper end, 357 
lower end, 427 

trochanter major, 381 

tibia, 459 
Epiphyses, sternum, 161 

scapula, 201 

humerus, 214 

radius, 301 

ulna, 312 

os innominatum, 335 

femur, 353 

tibia, 458 

fibula, 462 
Epitrochlea, 247 

Esmarch, double inclined plane, 405 
Etiology, general, 37 
Exciting causes, general, 38 
Experiments on bending, 83 

on partial fractures, 89 
External epicondyle of humerus, 254 

condyle of humerus, 259 
femur, 422 
Extension of thigh, 394, 413 

in fracture of vertebrae, 155 
vertical, 418 



FASCIA, relaxation of, 374 
Fatty embolism, 55 
Pelt splints, 65 
Femur, 352 

immediate dressing, 59 

absorption of neck, 364 

neck, within capsule, 354 
without capsule, 370 
within and without capsule, 377 
anatomy of, G-. K. Smith, 363 

differential diagnosis, 373 

trochanter major and base of neck, 
454 

epiphysis of trochanter major, 456 

shaft, 382 

lower third, 419 

measurement of, 386 

in children, 415 

external condyle, 422 

internal condyle, 424 

between condyles, 425 

base and between the condyles, 425 

delayed and non-union, 428 

separation of lower epiphysis, 427 
Fibula, 462 
Fingers, 332 
Fissures, 93 

cartilage, 95 

neck of femur, 353 
treatment, 95 
Forearm, 321 

immediate dressing, 58 
Four-tailed bandage for broken jaw, 127 
Fox apparatus, 189 
Fractures, 35 

delayed union, 74 

general etiology, 37 

general semeiology and diagnosis, 41 

general prognosis, 51 

general treatment, 55 

heredity, 38 

immediate dressings, 58 

incomplete, 83 

partial, 86 

treatment, 92 

repair of, 46 
Fracture-beds, 408 

Daniels, 408 

Burges, 408 

Crosby, 409 
Fracture-box, 487 



GANGEENE, after use of immovable 
apparatus, 69, 397, 417 
after fracture at base of condyles of 

humerus, 241 
after fracture of forearm, 323 
patella, 429 

arm and thigh, 298, 397, 399 
GUrretson's bandage, 126 
General division of fractures, 35 
etiology of fractures, 37 
semeiology of fractures, 41 
prognosis of fractures, 51 
treatment of fractures, 55 



INDEX. 



845 



Gibson, inferior splint, 125 

splint for femur, 368 
Gilbert, apparatus, 483 
Glenoid cavity of scapula, comminuted, 

198 
Gordon's splint, 293 
Gout, cause of fracture, 38 
Granger, fracture of epicondyle, 249 
Greater tubercle of humerus, 212 
Growth, arrest of, 230 
Gum-shellac splints, 65 
Gunshot fractures, 498 

treatment in, 502 
Gutta-percha splints, 65 

HAMMOND, jaw splint, 123 
Hartshorne, Edward, clavicle, 184 
Hays, radial splint, 287 
Head of radius, 263 

and anatomical neck of humerus, 206 
Head and neck of humerus, longitudinal 

fracture, 212 
Hereditary fragility, 38 
Hogden's fracture-cradle, 504 

wire suspension splint, 393 
Humerus, 205 

carrjnng function, 257 

immediate dressing, 58 

anatomical neck, 207 

head and neck, 206 

tubercle, 211 

longitudinal fracture of head and 
neck, 212 

surgical neck, 213, 218 

upper epiphysis, 213 

differential diagnosis, 220 

shaft, 227 

lower epiphysis, 238 

base of condyles, 237 

with splitting of condyles, 244 

condyles, 247 

internal epicondyle, 247 

external epicondyle, 254 

internal condyle, 255 

external condyle, 259 

delayed union, 229 
Hyoid bone, 131 

TLIUM, 340 

1 Immediate care, 56 

Immovable apparatus, 70 

patella, 453 

leg, 476 

thigh, 400 

dangers of, 70, 399, 476 
Impacted fractures, 37 

head and neck of humerus, 208 

neck of femur within capsule, 356 
without the capsule, 360 

radius, 275 
Incomplete fractures, 83 
Inferior maxilla, 111 
Interstitial absorption of femur, 364 
Internal condyle of humerus, 255 
Internal femur, 424 



Interdental splints, 121, 123 
Intra-uterine fracture, 39, 227, 458 
Ischium, 339 



JAW, lower, immediate care, 57 
fracture, 111 
upper, fracture, 104 
Joint, aspiration, 448 
fracture in, 459 

RINGSLEY, fracture of lower jaw, 124 
Knee, immediate dressing, 59 



LARYNX, fracture of, 135 
Lansdale, patella, 451 
Levis, hooks for patella, 444 
Liston, thigh splint, 385 

leg splint, 485 
Lower jaw, 111 

MALAR bone, 102 
Malgaigne, fracture of patella, 443 
of leg, 489 
Malleolus internus, 459 
Many-tailed bandage, 60 
Mason, ossa nasi, 99 
Maxilla, superior, 104 

inferior, 111 
Measurement of bones, 51 

of humerus, 236 

of thigh and leg, 386 
Metacarpus, 329 
Metatarsus, 496 
Metallic splints, 62 

Mollities ossium, causes of fracture, 38 
Monahan, fracture of astragalus, 492 
Moore, Colles's fracture, 276 

head of humerus, 216 

fracture of clavicle, 185 
Morbus coxae senilis, 364 
Muscular action, cause of fracture, 39 



NASAL bones, 96 
Neck of femur, 353 
within capsule, 354 
prognosis, 362 
without capsule, 370 
Neck of humerus, anatomical, 206 

surgical neck, 218 
Neck of lower jaw, 112 
of radius, 365 
of scapula, 198 
Nerves, causing fractures, 38 
Non-union, 74 
clavicle, 180 
femur, 428 
fibula, 466 
humerus, 229 
lower jaw, 117 
patella, 442 
ribs, 169 
tibia, 461 
tibia and fibula, 472 



I 



846 



INDEX 



Nose, fracture of, 96 
septum of, 100 







CCIPTJT, condyle of, 146 
Odontoid process of axis, 157 



mode of death, 159 
(Edema after removal of dressings, 53 
Ogston, fracture femur, 378 
Olecranon process, 302 

epiphyseal separation, 310 
Ossa nasi, 196 
Otis, hooks for patella, 445 

PALMER'S thigh splint, 393 
Paralysis after fracture of spine, 172 
humerus, 230 
inferior maxilla, 115 
clavicle, 180 
internal epicondyle of humerus, 

252 
base of condyle, 240 
upper end of fibula, 466 
Partial fracture, 86 
Patella, 429 

etiology of, 432 

anatomy and pathology of, 433 
immediate dressing, 59 
mode of union, 436 
treatment of, 443 
wiring in fractures, 445 
Pelvis, 335 

immediate dressing, 57 
traumatic separations, 336 
Phalanges of fingers, 332 

toes, 498 
Phelps, Charles, on patella, 445 
Pick, fracture femur, 378 
Pilcher, Oolles's fracture, 282 
Pins in non-union, 81 
Plaster-of- Paris, 70 
Prognosis, general, 51 
Pubes, 336 
Pulmonary venous embolism, 55 

RADIUS, 263 
Kadi us and ulna, 321 
Refracture of badly united legs, 490 
Repair of fracture, 46 
Resection for badly united fractures, 490 
Rheumatic arthritis, chronic, 364 
Rhinoplasty, 101 
Ribs, 167 

immediate dressing, 57 

cartilages of, 171 
Rim of acetabulum, 346 
Rodet, neck of femur, 355 
Roller, 60 
Rose, elbow splint, 242 



OACRUM, 349 

U Sacro-iliac symphysis, 350 
Salter's cradle for leg, 487 
Sayre, L. A., clavicle, 187 



Scapula, 194 

body, 194 

neck, 198 

acromion process, 199 

coracoid process, 203 

epiphyses of, 201 
Scraping in non-union, 80 
Scultetus, bandage, 61 
Semeiology, general, 41 
Senn's dressing, 378 
Septum narium, 100 
Seton in non-union, 80 
Setting bones, 60 
Seutin, dressing, 66 
Shaft of humerus, 227 
from m 

femur, 382 

radius, 269 

ulna, 317 
Shellac splints, 66 

Shoulder-joint; differential diagnosis, 220 
Side splints, 65 
Sling for broken jaw, 127 
Smith, E. P., radial splint, 288 
Smith, N. R., fracture of femur, 391 
Spine, immediate dressing, 57 
Spinous processes, vertebras, 140 

ilium, 340 
Splint, Bavarian, 480 
Splints, 63 
Starch bandage, 66 
Sternum, 161 

diastasis, 161 
Styloid process of radius, 300 

of ulna, 321 
Surgical neck of humerus, 218 
Swing-box for leg, 486 
Symphyses of pelvis, 336 

of pubes, 336 

sacro-iliac, 350 
Symphysis pubis, separation of, 336 
Syphilis, cause of fracture, 38 



HPARSUS, 491 

1 astragalus, 492 

calcaneum, 492 
Tenotomy in fractures of olecranon, 309 
Thomas, wiring jaw, 120 
Thyroid cartilage, 138 
Thyroid and cricoid cartilages, 139 
Tibia, 457 

Tibia and fibula, 470 
Toes, 498 

Trader's suspension apparatus, 487 
Transverse processes of spine, 142 
Treatment of fractures, general, 55 
Trelat's hooks, 444 

Trephining for fracture of vertebras, 145 
Tripolith, 68 
Trochanter major, 379 

fracture of, 380 
through, 379 

separation epiphysis, 381 
Tubercles of humerus, 211, 212 
Turner, patella splint, 452 



INDEX. 



847 



ULNA, resection of, 314 
^Ulna, 302 

shaft, 317 

coronoid process, 310 
olecranon process, 302 
styloid process, 321 
Upper epiphysis, humerus, 213 

femur, 381 
Upper maxillary bones, 104 



VAN WAG-ENEN'S suspension appa- 
ratus, 479 
Venous embolism, 55 
Vertebral arches, 43 
Vertebras, 140 

operations on, 146 

spinous processes, 140 

transverse processes, 142 

vertebral arches, 143 

removal of, 146 



Vertebras bodies, 147 
lumbar, 149 
dorsal, 151 
cervical, 151 

axis, 156 

atlas, 159 

alas and axis, 160 



WACKERHAGEN'S splints, 479 
Water-beds, 154 
Wire-beds, 154 
Wire-splints, 62 

Wire rack for fracture of leg, 488 
Wiring patella, 445 
Wooden splints, 63 
Wrist, 329 



ZUCKERKANDL, epicondyles, 251 
Zygomatic arch, 109 



PART II. DISLOCATIONS. 



ANAESTHETICS, 518 
Ancient dislocations, 511 

inferior maxilla, 520 

spine, 531 
CTIJS clavicle, outer end, 554 

humerus, 582 

head of radius forward, 616 

radius and ulna backward, 631 

femur, 735 
Ankle-joint, 770 

Anomalous dislocations of the hip, 726 
Anterior oblique dislocations, 731 
Astragalus, 783 
Atlas, dislocations of, 538 
Axillary artery, rupture of, 588 
vein, rupture of, 590 



B 



ICEPS, rupture or displacement of, 
596 



riALCANEUM, dislocation of, 795 
\J Carpus, 652 

backward, 655 
forward, 657 
congenital, 830 
Carpal bones among themselves, 661 
Carpo-metacarpal articulations, 663 
Cartilages, of ribs from sternum, 542 
of ribs, upon one another, 543 
in knee-joint, 768 
Clavicle, dislocations of, 544 
sternal end forward, 544 
sternal end upward, 548 
sternal end backward, 550 



Clavicle, dislocations of, acromial end 
upward, 552 

acromial end downward, 559 

under coracoid process, 560 

both ends, 561 

congenital, 825 
Clove-hitch, 517 
Compound pulleys, 518 
Compound dislocations of long bones, 803 

reduction in, 808 

non-reduction in, 810 

amputation in, 810 

tenotomy in, 811 

resection in, 811 
Congenital dislocations ; general observa- 
tions and history, 817 

general etiology, 818 

inferior maxilla, 820 

spine, 823 

pelvic bones, 824 

sternum, 824 

clavicle, 825 

shoulder, 825 

radius and ulna backward, 829 

head of radius, 830 

wrist, 830 

fingers, 831 

hip, 831 

patella, 837 

knee, 838 

tarsus, 841 

toes, 841 
Coxo-femoral dislocations, 678 

ancient dislocation of elbow, 637 
Cuboid, dislocations of, 797 
Cuneiform bones, dislocation of, 798 






848 



INDEX. 



DIEECT causes of dislocations, 513 
Dislocations, 511 
Division and nomenclature, 511 
Double dislocation of lower jaw, 519 



ELBOW-JOINT, 631 
Everted dorsal dislocation, 687 
Exciting causes, general, 513 
Extension by a twisted rope, 694 



FEMUR, dislocation of, 678 
dislocation on dorsum ilii, 681 

reduction by manipulation, 699 
reduction by extension, 712 
dislocation into ischiatic notch, 706 
below the tendon, 709 
dislocation into the foramen thy- 

roideum, 713 
dislocation upon the pubes, 720 
anomalous dislocations, 726 

downward and backward upor 

the body of the ischium, 732 

downward and backward int< 

lesser ischiatic notch, 732 
behind the tuber ischii, 732 
dislocation directly up, 729 
directly down, 733 
forward into perineum, 734 
ancient dislocations, 735 
partial dislocations, 740 
with fracture, 741 
in children, 679 
congenital, 831 
voluntary, 743 
Fibula, upper end forward, 781 
backward, 782 

displacement with fracture, 783 
lower end, 784 
« Fifth " dislocation of femur, 732 
Fingers, dislocations of first phalanx, 67' 
second and third, 676 
congenital, 831 
Foot, dislocation outward, 785 



GENERAL division, 511 
direct or exciting causes, 513 
predisposing causes, 512 
prognosis, 516 
pathology, 515 
treatment, 516 
symptoms, 513 



HEAD upon the atlas, 540 
Hip, congenital dislocations of, 831 
Humerus, dislocations of, 563 
double, 594 
downward, 564 
forward, 594 

fracture in reduction, 591 
with fracture, 592 
backward, 601 
upward, 606 



Humerus, dislocations of — partial, 612 
ancient, 582 

accidents during reduction, 588 
rupture of axillary artery, 588 
rupture of axillary vein, 590 
rupture of artery and vein, 590 
cerebral congestion, 591 
injury to axillary nerves, 591 
avulsion of arm, 591 
inflammation, 591 
congenital, 825 
Humero-scapular dislocation, 563 
Hyoid bone, dislocation of, 527 



TLIO-FEMORAL ligament, 684 
1 Ilio-pubic dislocation of femur, 720 
Indian " puzzle," 674 
Inferior maxilla, 519 

double dislocation, 519 
single dislocation, 524 
congenital dislocation, 820 
Internal arrangement of knee-joint, 768 
Ischio-pubic dislocation of femur, 713 
Ischiatic dislocation of femur, 706 



JARVIS'S adjuster, 695 
Jaw, lower, 519 



K 



NEE, slipping of cartilages, 768 
Kocher's method, 581 



LIGAMENTUM patellae, rupture of, 
759 

Long bones, compound dislocation in, 803 

Long head of biceps, displacement of, 613 

Lower jaw, 599 

double dislocation, 519 
single dislocation, 524 
simulating luxation of, 526 

Lumbar vertebrae, 529 

Lunare, 663 



MAGNUM, 662 
and cuneiform, 662 
Maxilla, inferior, congenital, 820 
Metacapus, 663 

Metacarpo-phalangeal articulation, 665 
Metatarsus, 800 
Middle carpal dislocation, 663 
tarsal dislocation, 784 



OCCIPITO-ATLOIDE AN dislocations, 
540 



PATELLA, outward, 751 
inward, 755 
on its axi*, 755 
upward, 759 
downward, 760 (note) 






INDEX, 



849 



Patella, spontaneous, 750 

congenital, 837 
Pathology, general, 515 
Pelvis, congenital, 824 
Peroneo-tibial, 831 
Phalanges, 667 

toes, 841 
Pisiform, 662 

Predisposing causes, general, 512 
Prognosis, general, 516 
Pseudo-luxations of inferior maxilla, 
Pulleys, 518 



526 



Q 



UADRICEPS, rupture of, 760 



RADIUS, head dislocated forward, 616 
backward, 621 

outward, 624 

downward,' 626 

congenital, 830 
Radius and ulna, backward, 631 

congenital, 829 

outward, 640 

inward, 646 

forward, 649 
Radius forward and ulna backward, 651 
Radio-carpal articulation, 652 
Radio-ulnar articulation, inferior, 658 
Ribs from vertebras, 541 

from sternum, 542 

one cartilage upon another, 546 
Rupture of quadriceps femoris, 760 
Rupture of biceps, 612 
Rupture of ligamentum patella, 759 



OACRO-SCIATIC dislocation, 706 
U Scaphoid, dislocation of, 797 
Scapula, voluntary, 747 
Shoulder, dislocations of, 563 
Single dislocation of lower jaw, 524 
"Sixth" dislocation of femur, 726 
Spine, 528 
Spontaneous or voluntary dislocations, 

743 
Sternum, 551 

congenita], 824 
Subcoracoid dislocation of humerus, 594 
Subclavicular dislocation of humerus, 594 
Subcotyloid dislocation of femur, 733 
Subluxation of the jaw, 526 
Subglenoid dislocation of the humerus, 

564 
Subpubic dislocation of femur, 713 
Subspinous dislocation of humerus, 601 
Symptomatology, general, 513 



Tarsus, os cuboides, 797 
os scaphoides, 797 
cuneiform bones, 798 
congenital, 841 
voluntary, 750 
Tendons, dislocation of, 613 
Thigh, 678 

Thumb, first phalanx, 667 
backward, 667 
forward, 674 
second phalanx, 676 
Tibia, dislocation of upper end, 760 
backward, 761 
forward, 762 
outward, 764 
inward, 765 

backward and outward, 766 
forward and outward, 767 
forward and inward, 767 
by rotation, 768 
congenital, 838 
lower end inward, 771 
outward, 775 
forward, 776 
backward, 779 
Tibio-tarsal dislocations, 770 
Toes, 802 

congenita], 841 



■ 



Tripod for vertical extension, 
Twisted-rope extension, 694 



■04 



ULXA, upper end backward, 629 
inward, 631 
lower end backward, 659 
forward, 660 
Unilateral dislocation of lower jaw, 524 



T7ERTEBRJE, 528 
T lumbar, 529 

dorsal, 530 

six lower cervical, 532 

atlas upon axis, 538 

head upon atlas, 540 

congenital dislocations, 823 
Voluntary and spontaneous dislocations 
743 

inferior maxilla, 747 

scapula, 747 

humerus, 748 

wrist-joint, 748 

phalanges of fingers, 748 

hip-joint, 748 

knee-joint, 750 

ankle-joint, 750 

tarsal joints, 750 

patella, 750 



HPARSUS, 784 



astragalus, 784 
astragalo-calcaneo-scaphoid, 794 
calcaneum, 795 
middle tarsal dislocation, 796 



W1XDLASS for extension, 694 
Wrist, 652 

y-LIGAMENT, 684 



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its position as the representative of the highest form of medical thought. 






COMMUTATION RATE. 

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SPECIAL OFFERS. 

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Lea Brothers & Co.'s Publications — Period., Manuals. 3 

THE MEDICAL NEWS VISITING LIST FOB 1891 

Is published in four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 120 
patients per month) ; Perpetual (undated, for 30 patients weekly per year) ; and Per- 
petual (undated, for 60 patients weekly per year). The 60-patient Perpetual is a novelty 
for the coming year, and consists of 25.6 pages of assorted blanks. The first three styles 
contain 32 pages of important data and 176 pages of assorted blanks. Each style is in 
one wallet-shaped book, leather-bound, with pocket, pencil, rubber, erasable tablet and 
catheter-scale. Price, each, $1.25. 

SPECIAL COMBINATIONS WITH VISITING LIST. 

The American Journal ($4) with Visiting List ($1.25), for ... $4.75 

The Medical News ($4) " " " " " ... 4.75 

The Journal and News ($7.50) " " """.... 8.25 
The Journal, News, Visiting List and Year-Book of Treatment ($1.25, 

see page 17) 8.50 



| list of diseases arranged alphabetically, giving 
under each a list of the prominent drugs em- 



This list is all that could be desired. It con- 
tains a vast amount of useful information, especi- 

ally for emergencies, and gives good table of doses i ployed in the treatment. When ordered, a Ready 
and therapeutics. — Canadian Practitioner. Reference Thumb-letter Index is furnished. This 

It is a masterpiece. Some of the features are j is a feature peculiar to this Visiting List. — Physi- 
peculiar to "The Medical News Visiting List," i dan and Surgeon, December, 
notably the Therapeutic Table, prepared from Dr. i For convenience and elegance it is not surpass- 
T. Lauder Brunton's book, which contains the ! able. — Obstetric Gazette, November. 



THE MEDICAL NEWS PHYSICIANS' LEDGEB. 

Containing 300 pages of fine linen " ledger " paper, ruled so that all the accounts of a 
large practice may be conveniently kept in it, either by single or double entry, for a long 
period. Strongly bound in leather, with cloth sides, and with a patent flexible back, 
which permits it to lie perfectly flat when opened at any place. Price, $4.00. 



HABTSHOBNE, HENBY, A. M., M. D. 9 LL. JD. 9 

Lately Professor of Hygiene in the University of Pennsylvania. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy, 
Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
Second edition, thoroughly revised and greatly improved. In one large royal 12mo. 
volume of 1028 pages, with 477 illustrations. Cloth, §4.25 ; leather, $5.00. 



The object of this manual is to afford a conven- 
ient work of reference to students during the brief 
moments at their command while in attendance 
upon medical lectures. It is a favorable sign that 
it has been found necessary, in a short space of 
time, to issue a new and carefully revised edition. 
The illustrations are very numerous and unusu- 
ally clear, and each part seems to have received 
its due share of attention. We can conceive such 
a work to be useful, not only to students, but to 
practitioners as well. It reflects credit upon the 



industry and energy of its able editor.— Boston 
Medical and Surgical Journal, Sept. 3, 1874. 

We can say with the strictest truth that it is the 
best work of the kind with which we are ac- 
quainted. It embodies in a condensed form all 
recent contributions to practical medicine, and is 
therefore useful to every Dusy practitioner through- 
out our country, besides being admirably adapted 
to the use of students of medicine. The book is 
faithfully and ably executed. — Charleston Medical 
Journal, April, 1875. 



NEILL, JOHN, M. !>., and SMITH, F. G., M. D. 9 

Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. 

An Analytical Compendium of the Various Branches of Medical 
Science, for the use and examination of Students. A new edition, revised and improved. 
In one large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4 ; leather, $4.75. 



LUDLOW, J. L. 9 M. I>., 

Consulting Physician to the Philadelphia Hospital, etc. 

A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of 
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which 
is added a Medical Formulary. Third edition, thoroughly revised, and greatly enlarged. In 
one 12mo. volume of 816 pages, with 370 illustrations. Cloth, $3.25 ; leather, $3.75. 

The arrangement of this volume in the form of question and answer renders it espe- 
cially suitable for the office examination of students, and for those preparing for graduation 



HOBLYN, BICHABD I)., M. L>. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Eevised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, $1.50 ; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table —Southern 
Medical and Surgical Journal. 



Lea Brothers & Co.'s Publications — Dictionaries. 



JUST READY. 



THE 



n^nonAL IHgdigal Dkjtioiiary 

INCLUDING 

English, French, German, Italian and Latin Technical Terms used in Medicine and 
the Collateral Sciences, and a Series of Tables of Useful Data. Z£ 



BY 



John f. Billing*, B[.D, LL.D, Ediq. and HMV, D.U.L, O^oq. 

Member of the National Academy of Sciences, Surgeon U. S. A., etc. 
WITH THE COLLABORATION OF 



Prof. W. O. ATWATER. JAMES M. FLINT, M. D., 

FRANK BAXER, M. D., J. H. KIDDER, M. D., 

S. M. BURNETT, M. D., WILLIAM LEE, M.D., 

W. T. COUNCILMAN, M. D., R. LORINI, M.D., 



WASHINGTON MATTHEWS, M. D. 
C. S. MINOT, M. D. 
H. C. YARROW, M. D., 



In two very handsome royal octavo volumes containing 1574 pages, 
with two colored plates. 

Per Volume— ClotJi, $6; Leather, $7 ; Half Morocco, Marbled Edges, $8.50. For Sale 
by Subscription only. Specimen pages on application. Address the Publishers. 



The publishers have great pleasure in presenting to the profession a new practical 
working dictionary embracing in one alphabet all current terms used in every depart- 
ment of medicine in the five great languages constituting modern medical literature. 

For the vast and complex labor involved in such an undertaking no one better quali- 
fied than Dr. Billings could have been selected. He has planned the work, chosen the 
most accomplished men to assist him in special departments, and personally supervised 
and combined their work into a consistent and uniform whole. 

Special care has been taken to render the definitions clear, sharp and concise. 
Pronunciation has been indicated by a simple phonetic spelling and by accents wherever 
necessary. The definitions are given in English, with synonyms in French, German 
and Italian of the more important words in English and Latin. 

Kegarded as a dictionary, therefore, this coming standard supplies the physician, 
surgeon and specialist with all information concerning medical words, simple and com- 
pound, found in English, giving correct spelling, clear, sharp definitions and proper 
pronunciation, and furthermore it enables him to consult foreign works and to understand 
the large and increasing number of foreign words used in medical English. It is especi- 
ally full in phrases comprising two, three or more words used in special senses in the 
various departments of medicine. 

The work is, however, far more than a dictionary, and partakes of the nature Of an 
encyclopaedia, as it gives in its body a large amount of valuable therapeutical and chemi- 
cal information, and groups in its tables, in a condensed and convenient form, a vast 
amount of important data which will be consulted daily by all in active practice. 

The completeness of the work is made evident by the fact that it defines 84,844 
separate words and phrases. 

The type has been most carefully selected for boldness and clearness, and everything 
has been done to secure ease and rapidity in use. 



Its scope is one which will at once satisfy the 
student and meet all the requirements of the med- 
ical practitioner. Clear and comprehensive defi- 
nitions of words should form the prime feature of 
any dictionary, and in this one the chief aim 
seems to be to give the exact signification and the 
different meanings of terms in use in medicine 
and the collateral sciences in language as terse as 
is compatible with lucidity. The utmost brevity 
and conciseness have been kept in view. The work 
is remarkable, too, for its fulness. The enumera- 
tions and subdivisions under each word heading 
are strikingly complete, as regards alike the Eng- 
lish tongue and the languages chiefly employed 
by ancient and modern science. It is impossible 
to do justice to the dictionary by any casual illus- 
tration. It presents to the English reader a 
thoroughly scientific mode of acquiring a rich 
vocabulary and offers an accurate and ready means 
of reference in consulting works in any of the 



three modern continental languages which are 
richest in medical literature. To add to its use- 
fulness as a work of reference some valuable 
tables are given. Another feature of the work is 
the accuracy of its definitions, all of which have 
been checked by comparison with many other 
standard works in the different languages it deals 
with. Apart from the boundless stores of informa- 
tion which may be gained by the study of a good 
dictionary, one is enabled by the work under notice 
to read intelligently any technical treatise in any 
of the four chief modern languages. There can- 
not be two opinions as to the great value and use- 
fulness of this dictionary as a book of ready refer- 
ence for all sorts and conditions of medical men. 
So far as we have been able to see, no subject has 
been omitted, and in respect of completeness it will 
be found distinctly superior to any medical lexicon 
yet published.— The London Lancet, April 5, 1890. 



Lea Brothers & Co.'s Publications — Anatomy. 



GRAY, HENRY, E. JR. S., 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. Edited by T. Pickering Pick, 
F. E. C. S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, 
Examiner in Anatomy, Koyal College of Surgeons of England. A new American from 
<the eleventh enlarged and improved London edition, thoroughly revised and re-edited 
*<by William W. Keen, M. D., Professor of Surgery in the Jefferson Medical College of 
Philadelphia. To which is added the second American from the latest English edition of 
Landmarks, Medical and Surgical, by Luther Holden, F. R. C. S. In one imperial 
octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of 
•edition in black: Cloth, $6; leather, $7; half Russia, $7.50. Price of edition in colors 
<see below): Cloth, $7.25; leather, $8.25 ; half Russia, $8.75.^ 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application to 
4hose details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engraving 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
4as been taken by the issue of the work with the arteries, veins and nerves distinguished 
by different colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
4he memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details Of the dissecting-room. Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume is published also in black alone, and maintained 
in this style at the price of former editions, notwithstanding its largely increased size. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
tias been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. 



The most popular work on anatomy ever written. 
It is sufficient to say of it that this edition, thanks 
■to its American editor, surpasses all other edi- 
tions — Jour, of the Amer. Med. Ass'n, Dec. 31, 1887. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy 
<throughout the civilized world comes to hand in 
such beauty of execution and accuracy of text 
•and illustration as more than to make good the 
large promise of the prospectus. It would be in- 
deed difficult to name a feature wherein the pres- 
ent American edition of Gray could be mended 
or bettered, and it needs no prophet to see that 
->4he royal work is destined for many years to come 
<£o hold the first place among anatomical text- 



books. The work is published with black and 
colored plates. It is a marvel of book-making. — 
American Practitioner and News, Jan. 21, 1888. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language. — Cincinnati 
Medical News, Nov. 1887. 

As the book now goes to the purchaser he is re- 
ceiving the best work on anatomy that is published 
in any language. — Virginia Med. Monthly, Dec. 1887. 

Gray's standard Anatomy has been and will be 
for years the text-book for students. The book 
needs only to be examined to be perfectly under- 
stood. — Medical Press of Western New York, Jan. 



Also for sale separate— 
HOLDER, ZUTSER, E. JR. C. S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 

Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
<£he Penna. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00. 



JDTmGLISOlT, ROBLEY, M.D., 

Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON ; A Dictionary of Medical Science : Containing 
■a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. Edited by Eichard J. Dunglison, M. D. In one very large and 
handsome royal octavo volume of 1139 pages. Cloth, $6.50 ; leather, raised bands, $7.50 ; 
^ery handsome half Russia, raised bands, $8. 

It has the rare merit that it certainly has no rival in the English language for accuracy 
<*nd extent of references. — London Medical Gazette. 



Lea Brothers & Co.'s Publications — Anatomy. 



ALLEN, HARRISON, M. !>., 

Professor of Physiology in the University of Pennsylvania, 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro* 
ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 38© 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section I. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fascia. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, of Digestion and Genito-UrinAry Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations', 
and General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00 ; very handsome half Russia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 

care, and are simply superb. There is as much 



It is to be considered a study of applied anatomy 
iD its widest sense — a systematic presentation of 
such anatomical facts as can be applied to the 
practice of medicine as well as of surgery. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con- 
sidered a dry subject. The department of Histol- 
ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 
iar with it. The illustrations are made with great 



of practical application of anatomical points to 
the every-day wants of the medical clinician as 
to those of the operating surgeon. In fact, few 
general practitioners will read the work without a> 
feeling of surprised gratification that so many 
points, concerning which they may never have- 
thought before are so well presented for their con- 
sideration. It is a work which is destined to be* 
the best of its kind in any language. — Medical 
Record, Nov. 25, 1882. 






CLARKE, W. B., F.R. C.S. & LOCKWOOD, C. B., F.R. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with, 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 31. 

Messrs.Clarke and Lock wood have written a book 
that can hardly be rivalled as a practical aid to the 
dissector. Their purpose, which is "how to de- 
scribe the best wayto display the anatomical 
structure," has been fully attained. They excel in 
a lucidity of demonstration and graphic terseness 
of expression, which only a long training and 



intimate association with students could have 

fiven. "With such a guide as this, accompanied 
y so attractive a commentary as Treves' Surgical 
Applied Anatomy (same series), no student could!? 
fail to be deeply and absorbingly interested in the- 
study of anatomy. — New Orleans Medical and Sur- 
gical Journal, April, 1884. 



TREVES, FREDERICK, F. R. C. 8., 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages^, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students , Series of Manuals? 
page 31. 



He has produced a work which will command a 
larger circle of readers than the class for which it 
was written. This union of a thorough, practical 
acquaintance with these fundamental branches, 
quickened by daily use as a teacher and practi- 
tioner, has enabled our author to prepare a work 
which it would be a most difficult task to excel.— 
The American Practitioner, Feb. 1884. 



This number of the "Manuals for Students" is- 
most excellent, giving just such practical knowl- 
edge as will be required for application in relieving 
the injuries to which the living body is liable. 
The book is intended mainly for students, but it 
will also be of great use to practitioners. The illus- 
trations are well executed and fully elucidate the* 
text.— Southern Practitioner, Feb. 1884. 



BELLAMY, EDWARD, F. R. C. S., 

Senior Assistant-Surgeon to the Charing- Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the- 
most Important Surgical Eegions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

WILSON, ERASMUS, F. R. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College o§ 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLELAND, JOHN, M. D., F. R. S., 

Professor of Anatomy and Physiology in Queen's College, Qalway. 

A Directory for the Dissection of the Human Body. La one 12mo. 
volume of 178 pages. Cloth, $1.25. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
In one royal 12mo. volume of 310 pages, with 220 
woodcuts. Cloth, $1.75. 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and? 
modified. In two octavo volumes of 1007 pages.,, 
with 320 woodcuts. Cloth, $6.00. 



Lea Brothers & Co.'s Publications — Physics, Physiol., Anat. 



DRAPER, JOHN C, M. D., LL. J>., 

Professor of Chemistry in the University of the City of New York. 
Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 

FROM THE PREFACE. 
The fact that a knowledge of Physics is indispensable to a thorough understanding of 
Medicine has not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Kobertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel. A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of the City of New York. 

Broadly speaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
•pursuit of this object whatever experience the author has gained during a long period of 
teaching this special branch of applied science. 

No man in America was better fitted than Dr. 
Draper for the task he undertook, and he has pro- 



While all enlightened physicians will agree that 
=a knowledge of physics is desirable for the medi- 
cal student, only those actually engaged m the 
'teaching of the primary subjects can be fully 
aware of the difficulties encountered by students 
*who attempt the study of these subjects without 
a knowledge of either physics or chemistry. 
These are especially felt by the teacher of physi- 
ology. 

It is, however, impossible for him to impart a 
knowledge of the main facts of his subject and 
^establish them by reasons and experimental dem- 
onstration, and at the same time undertake to 
teach db initio the principles of chemistry or phys- 
ics. Hence the desirability, we may say the 
necessity, for some such work as the present one. 



vided the student and practitioner of medicine 
with a volume at once readable and thorough. 
Even to the student who has some knowledge of 
physics this book is useful, as it shows him its 
applications to the profession that he has chosen. 
Dr. Draper, as an old teacher, knew well the diffi- 
culties to be encountered in bringing his subject 
within the grasp of the average student, and that 
he has succeeded so well proves once more that 
the man to write for and examine students is the 
one who has taught and is teaching them. The 
book is well printed and fully illustrated, and in 
every way deserves grateful recognition. — The 
Montreal Medical Journal July, 1890. 



robebtsoit 9 j. McGregor, m. a., m. b., 

Muirhead Demonstrator of Physiology, University of Glasgow. 
Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 31. 



The title of this work sufficiently explains the 
nature of its contents. It is designed as a man- 
ual for the student of medicine, an auxiliary to 
his text-book in physiology, and it would be particu- 
larly useful as a guide to his laboratory experi- 



ments. It will be found of great value to the 
practitioner. It is a carefully prepared book of 
reference, concise and accurate, and as such we 
heartily recommend it.— Journal of the American 
Medical Association, Dec. 6. 1884. 



Z> ALTON, JOHN €., M. JO., 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 



Dr. Dalton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 
ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands. — New Orleans 
Medical and Surgical Journal, Aug. 1885. 

In the progress of physiological study no fact 
■was of greater moment, none more completely 



revolutionized the theories of teachers, than the 
discovery of the circulation of the blood. This 
explains the extraordinary interest it has to all 
medical historians. The volume before us is one 
of three or four which have been written within a 
few years by American physicians. It is in several 
respects the most complete. The volume, though 
small in size, is one of the most creditable con- 
tributions from an American pen to medical history 
that has appeared. — Med. dk Surg. Rep., Dec. 6, 1884. 



BELL, F. JEFFREY, M. A., 

Professor of Comparative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 
with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 31. 

The manual is preeminently a student's book— it the best work in existence in the English 

■clear and simple in language and arrangement, language to place in the hands of the medical 

It is well and abundantly illustrated, and is read- student.— Bristol Medico-Chirurgical Journal, Mar. 

able and interesting. On the whole we consider 1886. 



ELLIS, GEORGE VINER, 

Emeritus Professor of Anatomy in University College, London, 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. 



ROBERTS, JOHN B., A. M., M. I)., 

Lecturer in Anatomy in the University of Pennsylvania. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 



8 Lea Brothers & Co.'s Publications — Physiology, Chemistry, 



CHAPMAN, HENRY C, M. D., 

Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia^ 

A Treatise on Human Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, $5.50 ; leather, $6.50. 

farther, and the latter will find entertainment an$ 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 
nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 



instruction in an admirable book of reference. 
North Carolina Medical Journal, Nov. 1887. 

The work certainly commends itself to both, 
student and practitioner. What is Most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
take place among the most valuable text-books. — 
Medical Age, Nov. 25, 1887. 

It is the production of an author delighted with 
his work, and able to inspire students with an en- 
thusiasm akin to his own. — American Practitioner 
and News, Nov. 12, 1887. 



DALTON, JOHN a, M. n., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and! 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one- 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth,, 
$5.00; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never been in any doubt as to its sterling 
worth. — N. Y. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



FOSTER, MICHAEL, M. D., F. R. S., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, 
Text-Book of Physiology. New (fourth) and enlarged American from the 
fifth and revised English edition, with notes and additions. Preparing. 

A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED. 



It is delightful to meet a book which deserves 
only unqualified praise. Such a book is now before 
us. It is in all respects an ideal text-book. With a 
complete, accurate and detailed knowledge of his 
subject, the author has succeeded in giving a 
thoroughly consecutive and philosophic account 
of the science. A student's attention is kept 
throughout fixed on the great and salient ques- 



tions, and his energies are not frittered away and* 
degenerated on petty and trivial details. Review- 
ing this volume as a whole we are justified in say- 
ing that it is the only thoroughly good text-boob 
of physiology in the English language, and that i* 
is probably the best text-book in any language. 
—Edinburgh Medical Journal, December 1889. 



FOWER, HENRY, M. B., F. R. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students 1 Series of Manuals, p. 31. 

SIMON, W., Fh. D., M. JD., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and' 
Professor of Chemistry m the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners^ 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates- 
illustrating 56 of the most important chemical tests. Cloth, $3.25. 

In this book the author has endeavored to meet 
the wants of the student of medicine or pharmacy 
in regard to his chemical studies, and he has suc- 
ceeded in presenting his subject so clearly that no 
one who really wishes to acquire a fair knowledge 
of chemistry can fail to do so with the help of this 
work. The largest section of the book is naturally 
that devoted to the consideration of the carbon 
compounds, or organic chemistry. An excellent 



feature is the introduction of a number of plates, 
showing the various colors of the most important 
chemical reactions of the metallic salts, of some 
of the alkaloids, and of the urinary tests. In the 
part treating of physiological chemistry the section- 
on analysis of the urine will be fouad' very practi- 
cal, and well suited to the needs of the practitioner 
of medicine.— The Medical Record, May 25, 1889. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Eemsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 

LEHM ANN'S MANUAL OF CHEMICAL PHYS- CARPENTER'S PRIZE ESSAY ON THE USE AND 
IOLOGY. In one octavo volume of 327 pages, Abuse of Alcoholic Liquors in Health and Dis- 
with 41 illustrations. Cloth, $2.25. „.,, . ,. - . **«>.«„>»' j- a „,i» 

CARPENTER'S HUMAN PHYSIOLOGY. Edited EASE - Wlth explanations of scientific words. Sm a 1L 
by Henry Power. In one octavo volume. 12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co.'s Publications — Chemistry. 



FBANKLAND, B., D. C. L., F. U.S., &JAFF, F. B., F. I. C. 9 



Assist. Prof, 'of Chemistry in the Normal 
School of Science, London. 



Professor of Chemistry in the Normal School 
of Science, London. 

Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 

* woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

This excellent treatise will not fail to take its 
place as one of the very best on the subject of 
which it treats. We have been much pleased 
with the comprehensive and lucid manner in 
which the difficulties of chemical notation and 



This work should supersede other works of its 
•class in the medical colleges. It is certainly better 
adapted than any work upon chemistry, with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 
chemical knowledge is behind the times, would 
do well to devote some of their leisure time to the 
study of this work. The descriptions and demon- 
strations are made so plain that there is no diffi- 
culty in understanding them. — Cincinnati Medical 
News, January, 1886. 



nomenclature have been cleared up by the writers. 
It shows on every page that the problem of 
rendering the obscurities of this science easy 
of comprehension has long and successfully 
engaged the attention of the authors. — Medical 
and Surgical Reporter, October 31, 1885. 



FOW2TES, GEORGE, JPh. D. 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical and Inorganic Chemistry. New American, from the twelfth English 
^edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood 
and a colored plate. Cloth, $2.75 ; leather, $3.25. 



Fownes' Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
-everywhere m this country and in England. As 
the science has advanced by the making of new 
-discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text-book with medi- 
cal students. In this work are treated fully : Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 



work as one of the very best text-books upon 
chemistry extant. — Cincinnati Med. News, Oct. '85. 
Of all the works on chemistry intended for the 
use of medical students, Fownes' Chemistry is 
perhaps the most widely used. Its popularity is 
based upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts' 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students.— New Orleans Medical 
and Surgical Journal, March, 1886. 



ATTFIELJD, JOHN, M. A., Fh. Z>., F. I. C, F. B. S„ Etc. 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
^and their Application to Medicine and Pharmacy. A new American, from the twelfth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of 782 pages, with 88 illustrations. Cloth, $2.75 ; leather, $3.25. 

Attfield's Chemistry is the most popular book 
among students of medicine and pharmacy. This 
popularity has a good, substantial basis. It rests 
upon real merits. Attfield's work combines in the 
happiest manner a clear exposition of the theory 
of chemistry with the practical application of this 
knowledge to the everyday dealings of the phy- 
sician and pharmacist. His discernment is shown 
not only in what he puts into his work, but also in 
what he leaves out. His book is precisely what 
the title claims for it. The admirable arrangement 
of the text enables a reader to get a good idea of 
chemistry without the aid of experiments, and 



again it is a good laboratory guide, and finally it 
contains such a mass of well-arranged information 
that it will always serve as a handy book of refer- 
ence. He does not allow any unutilizable knowl- 
edge to slip into his book; his long years of 
experience have produced a work which is both 
scientific and practical, and which shuts out 
everything in the nature of a superfluity, and 
therein lies the secret of its success. This last 
edition shows the marks of the latest progress 
made in chemistry and chemical teaching. — New 
Orleans Medical and Surgical Journal, Nov. 1889. 



BLOXAM, CSABLES L., 

Professor of Chemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
^aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 



the best manuals of general chemistry tn the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 

We know of no treatise on chemistry which 
contains so much practical information in the 
same number of pages. The book can be readily 
adapted not only to the needs of those who desire 
a tolerably complete course of chemistry, but also 
to the needs of those who desire only a general 
knowledge of the subject. We take pleasure in 
recommending this work both as a satisfactory 
text- book, and as a useful book of reference. — Bos- 
ton Medical and Surgical Journal, June 19, 1884. 



GBEENE, WILLIAM BE., M. L>., 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 

A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 
It is a concise manual of three hundred pages, I the recognition of compounds due to pathological 
giving an excellent summary of the best methods conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of the stu- 
for the estimation of their normal constituent and | dent or practitioner. — Boston Jl. of Chem. June, '80. 



10 



Lea Brothers & Co.'s Publications — Chemistry. 



REMSEN, IRA, M. D., JPh. D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore- 

Principles of Theoretical Chemistry, with special reference to the Constitis- 
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- 
some royal 12mo. volume of 316 pages. Cloth, $2.00 



This work of Dr. Remsen is the very text-book 
needed, and the medical student who has it at 
his fingers' ends, so to speak, can, if he chooses, 
make himself familiar with any branch of chem- 
istry which he may desire to pursue. It would be 
difficult indeed to find a more lucid, full, and at 
the same time compact explication of the philos- 
ophy of chemistry, than the book before us, and 
we recommend it to the careful and impartial 



examination of college faculties as the text-book of 
chemical instruction.— St. Louis Medical and Sur- 
gical Journal, January, 1888. 

It is a healthful sign when we see a demand for 
a third edition of such a book as this. This edi- 
tion is larger than the last by about seventy-five- 
pages, and much of it has been rewritten, thus* 
bringing it fully abreast of the latest investiga- 
tions.— N. Y. Medical Journal, Dec. 31, 1887. 



CHARLES, T. CRANSTOVN, M. J)., F. C. S., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo- 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 



Dr. Charles is fully impressed with the impor- 
tance and practical reach of his subject, and he 
has treated it in a competent and instructive man- 
ner. We cannot recommend a better book than 
the present. In fact, it fills a gap in medical text- 
books, and that is a thing which can rarely be said 



nowadays. Dr. Charles has devoted much space- 
to the elucidation of urinary mysteries. He does 
this with much detail, and yet in a practical and 
intelligible manner. In fact, the author has filled 
his book with many practical hints.— Medical Rec- 
ord, December 20, 1884. 



HOFFMANN, F., A.M., Ph.I>., & TOWER, F.B., Fh.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal) 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use oi 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

We congratulate the author on the appearance tion of them singularly explicit. Moreover, it is- 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



exceptionally free from typographical errors. "We 
have no hesitation in recommending it to those 
who are engaged either in the manufacture or the- 
testing of medicinal chemicals. — London Pharma- 
ceutical Journal and Transactions, 1883. 



CLOWES, FRANK, D. Sc, London, 

Senior Science- Master at the High School, Newcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth,, 
$2.50. 



This work has long been a favorite with labora- 
tory instructors on account of its systematic plan, 
carrying the student step by step from the simplest 
questions of chemical analysis, to the more recon- 
dite problems. Features quite as commendable 
are the regularity and system demanded of the 



student in the performance of each analysis. 
These characteristics are preserved in the present 
edition, which we can heartily recommend as a sat- 
isfactory guide for the student of inorganic chem- 
ical analysis. — New York Medical Journal, Oct. 9,. 
1886. 



RALFE, CHARLES H., M. J>., F. R. C. P., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16- 
illustrations. Limp cloth, red edges, $1.50. 
This is one of the most instructive little works 
that we have met with in a long time. The author 



is a physician and physiologist, as well as a chem 
ist, consequently the book is unqualifiedly prac 
tical, telling the physician just wnat he ought to 



is unqualifiedly prac- 

just wnat he ought to 

know, of the applications of chemistry in medi- 



See Students' Series of Manuals, page 31. 
cine. Dr. Ralfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Record, February 2, 1884. 



CLASSEN, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, $2.00. 

and then advancing to the analysis of minerals and 



It is probably the best manual of an elementary 
nature extant, insomuch as its methods are the 
best. It teaches by examples, commencing with 
single determinations, followed by separations, 



such products as are met with in applied chemis- 
try. It is an indispensable book for students in 
chemistry.— Boston Journal of Chemistry, Oct. 1878„ 



Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Therap. 11 



HAKE, HOB ART AMORT, B. Sc, M. D., 

Clinical Professor of Diseases of Children and Demonstrator of Therapeutics in the University of 
Pennsylvania; Secretary of the Convention for the Revision of the United States Pharmacopoeia of 
1890. 

A Text-Book of Practical Therapeutics; With Especial Eeference to the 
Application of Kemedial Measures to Disease and their Employment upon a Rational 
Basis. With special chapters by Drs. G. E. de Schweinitz, Edward Martin, 
J. Howard Reeves and Barton C. Hirst. In one handsome octavo volume of 622 
pages. Cloth, $3.75 ; leather, $4.75. Just ready. 



That the student is too often required to perform 
acrobatic feats of memory and invention in asso- 
ciating and reconciling widely separated state- 
ments is certain, and disgust over his failure is 
apt to develop him into a physician, without faith 
in the reasonableness of his art. Dr. Hare has 
obviated this difficulty by comprising in one 
cover a work on therapeutics and on treatment, 
each part being so interwoven with the other by 
references that there will be the least possible diffi- 
culty in learning and remembering the nature of 
therapeutic resources, and in using them to the 
best advantage. The portion devoted to treat- 
ment occupies at least one-half of the work, with 
•clear directions for the therapeutic measures to 
be employed, together with the reasons for the 
choice of drugs, according to the varying stages 
and symptoms. — Medical Age, September 25, 1890. 

We may say without exaggeration that the pres- 



ent volume is in many respects unique and a great 
credit to the author. Dr. Hare is already well 
known as an able experimental, didactic and 
clinical therapeutist, a happy combination, which 
has eminently fitted him for the preparation of th e 
present work. He is thoroughly acquainted with 
the latest contributions to therapeutical science, 
and his book represents the actual state of the 
science. It is a model of concise, clear and forci- 
ble description, an exponent of plain facts, and a 
thoroughly practical guide to the rational treat- 
ment of disease. Books like this make a lastiDg 
impression. We heartily commend the present 
volume to the student, the scientific therapeutist 
and the general practitioner, not only as a most 
satisfactory text-book, but also as a highly valua- 
ble work of reference. We bespeak for Dr. Hare's 
" Practical Therapeutics " the greatest success in 
every way.-- University Medical Magazine, Nov. 1890. 



BRTJNTOW, T. LAUDER, M.D., D.Sc, E.R.S., F.R.C.P., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. 

A Text-Book of Pharmacology, Therapeutics and Materia Medica; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
Third edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5.50 ; leather, $6.50. 



No words of praise are needed for this work, for 
it has already spoken for itself in former editions. 
it was by unanimous consent placed among the 
foremost Dooks on the subject ever published in 
any language, and the better it is known and studied 
the more highly it is appreciated. The present 
•edition contains much new matter, the insertion 
of which has been necessitated by the advances 



made in various directions in the art of therapeu- 
tics, and it now stands unrivalled in its thoroughly 
scientific presentation of the modes of drug action. 
No one who wishes to be fully up to the times in 
this science can afford to neglect the study of Dr. 
Brunton's work. The indexes are excellent, and 
add not a little to the practical value of the book. 
—Medical Record, May 25, 1889. 



MAISCH, JOHNM., Fhar. D., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New (4th) edition, thoroughly revised. In one handsome royal 12mo. 
volume of 529 pages, with 258 illustrations. Cloth, $3. Just ready. 

fore his eyes. That it answers its purposes in this 
respect the rapid succession of editions is the best 
evidence. It is the favorite book of the American 
student even outside of Maisch's several hundred 
personal students. The arrangement of its con- 
tents shows the practical tendency of the book. 
Maisch's system of classification is easy and com- 
prehensive.— Pharmaceutische Zeitung, Germany, 



For everyone interested in materia medica, 
Maisch's Manual, first published in 1882, and now 
in its fourth edition, is an indispensable book. 
For the American pharmaceutical student it is 
•the work which will give him the necessary knowl- 
edge in the easiest way, partly because the text is 
brief, concise, and free from unnecessary matter, 
and partly because of the numerous illustrations, 
which bring facts worth knowing immediately be- 



JPARRISH, EDWARD, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
A Treatise on Pharmacy : Designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. 

No thorough-going pharmacist will fail to possess 
himself of so useful a guide to practice, and no 
physician who properly estimates the value of an 
accurate knowledge of the remedial agents em- 
ployed by him in daily practice, so far as their 
miscibility, compatibility and most effective meth- 



ods of combination are concerned, can afford to 
leave this work out of the list of their works of 
reference. The country practitioner, who must 
always be in a measure his own pharmacist, will 
find it indispensable. — Louisville Medical News, 
March 29, 1884. 



HERMAJnf, Dr. L., 

Professor of Physiology in the University of Zurich. 
Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Bobert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. 12mo., 199 pages, with 32 illustrations. Cloth, $1.50. 



STILLE, ALFRED, M. D., LL. D., 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 

Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. 
Oloth, $10.00; leather, $12.00. 



12 Lea Brothers & C6.'s Publications — Mat. Med., Therap. 



STILLE, A., M. !>., LL. Z>., & MAISCH, J. M., Fhar. D. P 

Prof, of Mat. Med. and Botany in Philm 
College of Pharmacy, Sec 1 y to the Amer> 
can Pharmaceutical Association. 



Professor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



The National Dispensatory. 

CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF 
MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPOEIAS OF THE 
UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS 
REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- 
nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price 
in cloth, $7.25 ; leather, raised bands, $8.00. *x*This work will be furnished with Patent 
Ready Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding. 

In this new edition of The National Dispensatory, all important changes in the- 
recent British Pharmacopoeia have been incorporated throughout the volume, while in* 
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical 
novelties which have been established in professional favor since the publication of the 
third edition two years ago. Since its first publication, The National Dispensatory" 
has been the most accurate work of its kind, and in this edition, as always before, it may 
be said to be the representative of the most recent state of American, English, German 
and French Pharmacology, Therapeutics and Materia Medica. 



It is with much pleasure that the fourth edition 
of this magnificent work is received. The authors 
and publishers have reason to feel proud of this, 
the most comprehensive, elaborate and accurate 
work of the kind ever printed in this country. It 
is no wonder that it has become the standard au- 
thority for both the medical and pharmaceutical 
profession, and that four editions have been re- 
quired to supply the constant and increasing 
demand since its first appearance in 1879. The 
entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 



discovery have received due attention. — Kansas* 
City Medical Index, Nov. 1887. 

We think it a matter for congratulation that the- 
profession of medicine and that of pharmacy have- 
shown such appreciation of this great work as to call 
for four editions within the comparatively brief 
period of eight years. The matters with which it 
deals are of so practical a nature that neither the- 

f)hysician nor the pharmacist can do without the 
atest text-books on them, especially those that are- 
so accurate and comprehensive as this one. The 
book is in every way creditable both to the authors- 
and to the publishers. — New York Medical Journal, 
May 21, 1887. 



FARQUHARSOJT, ROBERT, M. JO., F. R. C. F., LL. L>.? 

Lecturer on Materia Medica at St. Mary's Hospital Medical School, London. 

A Guide to Therapeutics and Materia Medica. New (fourth) American,, 
from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By~ 
Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical 
Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo. 
volume of 581 pages. Cloth, $2.50. 



It may correctly be regarded as the most modern 
work of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 
a place in the British and United States Pharma- 
copoeias, as well as considering all non-official but 
important new drugs, it becomes in fact a miniature 
dispensatory. — Pacific Medical Journal, June, 1889. 

An especially attractive feature is an arrange- 
ment by which the physiological and therapeutical 



actions of various remedies are shown in parallel 
columns. This aids greatly in fixing attention and 
facilitates study. The American editor has en- 
larged the work so as to make it include all the 
remedies and preparations in the U. S. Pharma- 
copoeia. The book is a most valuable addition to* 
the list of treatises on this most important subject. 
— American Practitioner and News, Nov. 9th, 1889. 



EDES, ROBERT T., M. I)., 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 



Use of Students and Practitioners. Octavo 
The present work seems destined to take a promi- 
nent place as a text-book on the subjects of which 
it treats. It possesses all the essentials which we 
expect in a book of its kind, such as conciseness, 
clearness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated of. The clinical index at 
the end will be found very useful. We heartily 



544 pages. Cloth, $3.50 ; leather, $4.50. 
commend the book and congratulate the author 
on having produced so good a one.— N. Y. Medical 
Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action.— Pharmaceutical Era, Jan. 1888. 



BRUCE, J. MITCHELL, M. !>., F. R. C. F., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. 

Materia Medica and Therapeutics. An Introduction to Eational Treatment. 
Fourth edition. 12mo., 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 31. 

GRIFFITH, ROBERT EGLESFIELB, M. D. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch^ 
Phar.D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations, Cloth, $4.50 ; leather, $5.50. 



Lea Brothers & Co.'s Publications — Pathol., Histol. 



13 



GBEEN, T. HEJSBT, M. D., 

Lecturer on Pathology and Morbid Anatomy at Charing- Cross Hospital Medical School, London. 

Pathology and Morbid Anatomy. New (sixth) American from the seventh 
revised English edition. Octavo, 539 pp., with 167 engravings. Cloth, $2.75. Just ready. 



The Pathology and Morbid Anatomy of Dr. 
Green is too well known by members of the medi- 
cal profession to need any commendation. There 
is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work of the kind 
with which we are acquainted. The works of 
German authors upon pathology, which have been 



translated into English, are too abstruse for the 
physician. Dr. Green's work precisely meets his 
wishes. The cuts exhibit the appearances of 
pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is evidence that we have not spoken too 
much in its favor.— Cincinnati Medical Neves, Oct. 



PAYNE, JOSEPH F, M. D., F. B. C. P., 

Senior Assistant Physician and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. 
A Manual of General Pathology. Designed as an Introduction to the Prac- 
tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50. 
Knowing, as a teacher and examiner, the exact i cal factors in those diseases now with reasonable 



needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 



certainty ascribed to pathogenetic microbes. In 
this department he has been very full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of research, is alone worth the price of the 
book, several times over, to every student of 



tion of disease, and more especially to the etiologi- | pathology. — St. Louis Med. and Surg. Jour., Jan. '5 



SEJVN, NICHOLAS, M.D., Ph.JD., 

Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago. 
Surgical Bacteriology. New (second) edition. In one handsome octavo 
about 250 pages, with 13 plates, of which 9 are colored. In press. 



of 



COATS, JOSEPH, M. D., F. F. P. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise on Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 

Medical students as well as physicians, who manner, the changes from a normal condition 
desire a work for study or reference, that treats effected in structures by disease, and points out 
the subjects in the various departments in a very the characteristics of various morbid agencies, 
thorough manner, but without prolixity, will cer- : so that they can be easily recognized. But, not 
tainly give this one the preference to any with I limited to morbid anatomy, it explains fully how 
which we are acquainted. It sets forth the most j the functions of organs are disturbed by abnormal 
recent discoveries, exhibits, in an interesting | conditions.— Cincinnati Medical News, Oct. 1883. 



WOOJDHEAD, G. SIMS, M. L>., F. B. C. P., E., 

Demonstrator of Pathology in the University of Edinburgh. 
Practical Pathology. A Manual for Students and Practitioners. In one beau- 
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 

It forms a real guide for the student and practi- 
tioner who is thoroughly in earnest in his en- 
deavor to see for himself and do for himself. To 
the laboratory student it will be a helpful com- 
panion, and all those who may wish to familiarize 
themselves with modern methods of examining 
morbid tissues are strongly urged to provide 



themselves with this manual. The numerous 
drawings are not fancied pictures, or merely 
schematic diagrams, but they represent faithfully 
the actual images seen under the microscope. 
The author merits all praise for having produced 
a valuable work.— Medical Record, May 31, 1884. 



SCHAFEB, EDWABJD A., F. B. S., 

Jodrell Professor of Physiology in University College, London. 

The Essentials of Histology. In one octavo volume of 246 pages, with 
281 illustrations. Cloth, $2.25. 

This admirable work was greatly needed. It I cially adapted for laboratory work, at the same 
has been written with the object of supplying i time it is intended to serve as an elementary 
the student with directions for the microscopical text-book of histology, comprising all the essen- 
examination of the tissues, which are given in a j tial facts of the science. — The Physician and Sur- 
clear and understandable way. Although espe- | geon, July, 1887. 



KLEIN, E., M. I)., F. B. S., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London. 
Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, 
with 194 illus. Limp cloth, $1.75. See Students? Series of Manuals, page 31. 



Considered with regard to its contents, it can 
only be looked on as a large and comprehensive 
volume. New and original illustrations have been 
added, with the help of which the structure of each 
tissue becomes clear to the reader. A copious 



index affords a ready reference to the histology of 
every tissue and organ, and presents, at the same 
time, a complete glossary of the scientific terms.— 
Provincial Medical Journal, May 1, 1889. 



PEPPEB, A. J., M. B., M. S., F. B. C. S., 

Surgeon and Lecturer at St. Mary's Hospital, London. 
Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 31. 

Its form is practical, its language is clear, and I in it nothing that is unnecessary. The list of 
the information set forth is well-arranged, well- subjects covers the whole range of surgery.— New 
indexed and well-illustrated. The student will find | York Medical Journal, May 31, 1884. 



14 



Lea Brothers & Co.'s Publications — Practice of Med. 



FLINT, AUSTIN, M. D., LI. &., 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- 
vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome 
octavo volume of 1160 pages, with illustrations. Cloth, $5.50 ; leather, $6.50. 

in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and' 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art. — Cincinnati Medical Newt, Oct. 1886. 



No text-book on the principles and practice of 
medicine has ever met in this country with such 
general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 



BRISTOWE, JOHN SYER, M. JD., LL. !>., M R. S., 

Senior Physician to and Lecturer on Medicine at St. Thomas' Hospital, London. 

A Treatise on the Science and Practice of Medicine. Seventh edi- 
tion. In one large octavo volume of 1325 pages. Cloth, $6.50 ; leather, $7.50. Just ready. 



The remarkable regularity with which new edi- 
tions of this text-book make their appearance is 
striking testimony to its excellence and value. 
This, too, in spite of the numerous rivals for the 
favor of the student which have been put forth 
within the sixteen years since Bristowe's" Medi- 
cine" first appeared. Nor can it be said that the 
author himself has failed to keep his manual 
abreast of advancing knowledge, arduous as that 
task must prove. So long as there is shown such 
care and circumspection in the inclusion of all 
new matter that has stood the test of criticism, so 
long will this work retain the favor which it has 
always met. For it is a work that is built on a 
stable foundation, systematic, scientific and prac- 
tical, containing the matured experience of a 



physician who has every claim to be considered 
an authority, and composed in a style which at- 
tracts the practitioner as much as the student. No 
one can say that this book has obtained a success 
which was undeserved, and we trust that its author 
will long continue to supervise the production of 
fresh editions for the advantage of the coming 
generation of medical students. — The Lancet, July 
12, 1890. 

Dr. Bristowe's now famous treatise appears in 
its seventh edition. It has long passed the stage 
in which it requires critical examination or com- 
mendation, and has thoroughly established itself 
as among the most complete and useful of text- 
books.— British Medical Journal, September 27, 1890. 



HARTSHORNE, HENRY, M. JD., LL. JD., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 

this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 



Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen.— Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment. — Chicago 
Medical Journal and Examiner, April, 1882. 



REYNOLDS, J. RUSSELL, M. JD., 

Professor of the Principles and Practice of Medicine in University College, London. 
A System of Medicine. With notes and additions by Henry. Hartshorne, 
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Russia, raised bands, 
$6.50. Per set, cloth, $15; leather, $18. Sold only by subscription. 



STILLE, ALFRED, M. D., LL. &., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Cholera : Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. 

WATSON, SIR THOMAS, M. I)., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. 



Lea Brothers & Co.'s Publications — System of Med. 



15 



For Sale by Subscription Only, 



A System of Practical Medicine. 

BY AMERICAN AUTHORS. 
Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
ClilNICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 
Hospital of the University of Pennsylvania. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. 



In this great work American medicine is for the first time reflected by its worthiest 
teachers, and presented in the rail development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the 
!North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has been 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus will be sent to any address on application to the publishers. 



These two volumes bring this admirable work 
to a close, and fully sustain the high standard 
reached by the earlier volumes; we have only 
therefore to echo the eulogium pronounced upon 
them. We would warmly congratulate the editor 
and his collaborators at the conclusion of their 
laborious task on the admirable manner in which, 
from first to last, they have performed their several 
duties. They have succeeded in producing a 
work which will long remain a standard work of 
reference, to which practitioners will look for 
guidance, and authors will resort for facts. 
From a literary point of view, the work is without 
any serious blemish, and in respect of production, 
it has the beautiful finish that Americans always 
give their works.— Edinburgh Medical Journal, Jan. 
1887. 

* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, July 26, 1886. 

This huge volume forms a fitting close to the 
great system of medicine which in so short a time 
has won so high a place in medical literature, and 
has done such credit to the profession in this 
country. Among the twenty-three contributors 
are the names of the leading neurologists in 
America, and most of the work in the volume is of 
the highest order.— Boston Medical and Surgical 
Journal, July 21, 1887. 

We consider it one of the grandest works on 
Practical Medicine in the English language. It is 
a work of which the profession of this country can 
feel proud. Written exclusively by American 



physicians who are acquainted with all the varie 
ties of climate in the United States, the character 
of the soil, the manners and customs of the peo- 
ple, etc., it is peculiarly adapted to the wants 
of American practitioners of medicine, and it 
seems to us that every one of them would desire 
to have it. It has been truly called a "Complete 
Library of Practical Medicine," and the general 
practitioner will require little else in his round 
of professional duties. — Cincinnati Medical Neics, 
March, 1886. 

Each of the volumes is provided with a most 
copious index, and the work altogether promises 
to be one which will add much to the medical 
literature of the present century, and reflect great 
credit upon the scholarship and practical acumen 
of its authors. — The London Lancet, Oct. 3, 1885. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 
lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome 
of American brains, and is marked throughout 
by much of the sturdy independence of thought 
and originality that is a national character] stic. 
Yet nowhere is there lack of study of the most 
advanced views of the day.— North Carolina Medi- 
cal Journal, Sept. 1886. 



16 



Lea Brothers & Co.'s Publications— Clinical Med., etc. 



FOTHERGILL, J. M., M. !>., Edin., M. R. C. P., Zond., 

Physician to the City of London Hospital fo*- Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75 ; leather, $4.75. 

To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 



between the two clearly stated, cannot fail to prove 



This is a wonderful book. If there be such a 
thing as " medicine made easy," this is the work to 
accomplish this result.— Fa. Med. Month., June,'87. 

It is an excellent, practical work on therapeutics, 
well arranged and clearly expressed, useful to the 



great convenience to many thoughtful but busy student and young practitioner, perhaps even to 



physicians. The practical value of the volume 
greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition. — N. Y. Med. Jour., June 11,'87. 



the old.— Dublin Journal of Medical Science, March, 
1888. 

We do not know a more readable, practical and 
useful work on the treatment of disease than the 
one we have now before us.— Pacific Medical and 
Surgical Journal, October, 1887. 



VAUGHAlSr, VICTOR C. 9 Ph. !>., M. 2>., 

Prof, of PJiys. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. 

and NOVY, FREDERICK G., M. D. 

Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. 

Ptomaines and Leucomaines, or Putrefactive and Physiological 
Alkaloids. New Edition. In one handsome 12mo. vol. of about 300 pages. Preparing. 

FINLAYSON, JAMES, M. I)., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc 

Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephenson on Diseases of 
*he Female Organs; Dr. Robertson on Insanity; Dr. Gemmell on Physical Diagnosis; 
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- 
taking, Family History and Symptoms of Disorder in the Various Systems. New edition. 
In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 

treatise on medical diagnosis, in which every sign 
and symptom of disease is carefully analyzed, and 
their relative significance in the different affec- 
tions in which they occur pointed out. From their 
synthesis the student can accurately determine 
the disease with which he has to deal. The book 
has no competitor, nor is it likely to have as long 
as future editions maintain its present standard of 
excellence. The general practitioner will find 
many practical hints in its pages, while a careful 
study of the work will save him from many pitfalls 
in diagnosis. — Liverpool Medico- Chirurgical Jour- 
nal, January, 1887. 



The profession cannot but welcome the second 
edition of this very valuable work of Finlayson 
and his collaborators. The size of the book has 
been increased and the number of illustrations 
nearly doubled. The manner in which the subject 
is treated is a most practical one. Symptoms 
alone and their diagnostic indications form the 
basis of discussion. The text explains clearly and 
fully the methods of examinations and the con- 
clusions to be drawn from the physical signs.— 
The Medical News, April 23, 1887. 

We are pleased to see a second edition of this 
admirable book. It is essentially a practical 



BROA&BE2TT, W. H., M. !>., F. R. C. P., 

Physician to and Lecturer on Medicine at St. Mary's Hospital, London. 
The Pulse, In one 12mo. volume of 312 pages. Cloth, $1.75. 
Series of Clinical Manuals, page 31 

This little book probably represents the best 
practical thought on this subject in the English 
language. A correct interpretation of the pulse, 
with its almost infinite modifications, brought 
about by almost unlimited bodily variations, can 



Just ready. See 



only be achieved by experience, and, as an aid 

,1, nothing a 
service than this brochure on the study of the 



toward attaining this goal, nothing will be of more 



pulse. — The American Journal of Medical Sciences, 
September, 1890. 



KABERSHON, S. O., M. JD. 9 

Senior Physician to and late Lect. on Principles and Practice of Med. at Guy's Hospital, London. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 



This valuable treatise on diseases of the stomach 
and abdomen will be found a cyclopaedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 
rectum. A fair proportion of each chapter is 
devoted to symptoms, pathology, and therapeutics. 
The present edition is fuller than former ones in 
many particulars, and has been thoroughly revised 
and amended by the author. Several new chap- 
ters have been added, bringing the work fully up 



to the times, and making it a volume of interest to 
the practitioner in every field of medicine and 
surgery. Perverted nutrition is in some form 
associated with all diseases we have to combat, 
and we need all the light that can be obtained on 
a subject so broad and general. Dr. Habershon's 
work is one that every practitioner should read 
and study for himself. — N. Y. Medical Journal, 
April, 1879. 



TANNER, THOMAS HAWKES, M. D. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Kevised and enlarged by Tilbury Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 

LECTURES ON THE STUDY OF FEVER. By LA ROCHE ON YELLOW FEVER, considered in 



A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50. 
A TREATISE ON FEVER. By Robebt D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25 



its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and hand- 
some octavo volumes of 1468 pp. Cloth, $7.00. 



Lea Brothers & Co.'s Publications — Hygiene, Electr., Praet. 17 
BARTHOLOW, ROBERTS, A. M., M. B., LL. B., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 
308 pages, with 110 illustrations. Cloth, $2.50. 



The fact that this work has reached its third edi- 
tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
■electricity,demonstrates its claim to be considered 
s. practical treatise of tried value to the profession. 
The matter added to the present edition embraces 



the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner.— The Medical JSews, May 14, 1887. 



YEO, I. BTJRNEY, M. B., F. R. C. P., 

College, London, and Physician to King's College 



Professor of Clinical Therapeutics in King\ 
Hospital. 

Food in Health and Disease. In one 12mo. volume of §90 pages 
Just ready. See Series of Clinical Manuals, page 31. 



Cloth, $2. 



Dr. Yeo is fully master of his subject and he 
supplies in a compact form nearly all that the 
practitioner requires to know on the subject of 
diet. The work is divided into two parts— food in 
health and food in disease. Dr. Yeo has gathered 
together from all quarters an immense amount of 
-useful information within a comparatively small 



compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo.— British Medical 
Journal. Feb. 8, 1890. 



RICHARDSON, B. W., M.B., LL. B., F.R.S., 

Fellow of the Royal College of Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5. 

tive collection of data upon the diseases common 
to the race, their origins, causes, and the measures 



Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
intelligent and practical form. There is perhaps 
no similar work written for the general public 
that contains such a complete, reliable and instruc- 



for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion cf 
the question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable.— The 
American Journal of the Medical Sciences, April, 1884. 



THE YEAR-BOOK OF TREATMENT FOR 1890. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 329 pages. Cloth, $1.25. Just ready. 
#*x For special commutations with periodicals see pages 1 and 2. 



In the present issue of the Year- Book of Treat- 
ment we find the usual clear, concise, complete 
and accurate epitome of the chief advances made 
in the treatment of disease during a year. The 
■different subjects are arranged in sections under 
the heads of the principal systems of the body. 
The serial medical literature of England, Amer- 
ica and of the Continent has been laid under 
contribution, with the result that a large mass of 



information, valuable to the practitioner, is pre- 
sented for his immediate reference. Brief notices 
of the most important new books on each subject 
add greatly to the value of the annual retrospect. 
Such a book, produced as it is in an elegant and 
convenient form and at a very low price, ought 
to be in the hands of every member of the profes- 
sion.— The Practitioner, Feb. 1890. 



THE YEAR-BOOKS of TREATMENT for 1886 and 87. 

Similar to above. 12mo., 320-341 pages. Limp cloth, $1.25 each. 

SCHREIBER, JOSEPH, M. B. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. Cloth, $2.75. 



3TURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis. 
M. D. Edited by Frank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, $1.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth. $2.50. 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 
M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand 
some octavo volume of 302 pp. Cloth, $2.75. 



HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 

FULLER ON DISEASES OF THE LCJNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 



18 Lea Brothers & Co.'s Publications — Throat, Lungs, Heart, Nerves. 



FLINT, AUSTIN, M. I)., LL. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College^ N. Y. 

A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. New (fifth) edition. 
Edited by James C. Wilson, M. D., Jefferson Medical College, Philadelphia. In one 
handsome royal 12mo. volume of 274 pages, with 12 illustrations. Cloth, $1.75. Just ready. 

FROM THE EDITOR'S PREFACE TO THE NEW EDITION. 

The value of this manual is to be discovered in the clearness and appropriateness of 
its style, the accuracy of its statements, its scientific method, and the practical treatment 
of subjects at once difficult and essential to the student of medicine. In respect to 
these qualities it stands and will long stand alone among books devoted to auscultation 
and percussion. The present revision, undertaken in response to a very general demand 
will, it is hoped, serv^ to prolong the availability of a work which, while already a medical 
classic, shows no sign of waning in popularity and usefulness among teachers and students. 



BY THE SAME AUTHOR. 

A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

BROWNE, LENNOX, F. B. C. S., E., 

Senior Physician to the Central, London Throat and Ear Hospital. 

A Practical Guide to Diseases of the Throat and Nose, including 
Associated Affections of the Ear. New (third) and enlarged edition. In one 
imperial octavo volume of 734 pages, with 120 illustrations in color, and 235 engravings 
on wood. Cloth, $6.50. Just ready. 



The third edition of Mr. Lennox Browne's in- 
structive and artistic work on " The Throat and 
Its Diseases" appears under the title of "The 
Throat and Nose and Their Diseases." This 
change has been rendered desirable by the ad- 
vances made during the last decade in rhinology. 
The nasal sections, which extend to upwards of 
100 pages, give in a short space the best account 
of the present position of rhinology with which 
we are acquainted. The engravings in this hand- 
some volume are of the same high order as here- 
tofore, and more numerous than ever; they can- 
not fail to be of the greatest assistance to senior stu- 
dents and practitioners. The instruments, either 
figured or described, are those which, as the result 



of experience, Mr. Browne has found to be of the 
greatest utility in diagnosis and treatment; they are 
most simple, inexpensive and easily kept aseptic — 
points of much importance. We have on a former 
occasion eulogised the beautiful and typical col- 
ored plates drawn on stone by the author-artist 
himself, and forming in themselves a valuable 
and instructive atlas, the equal of which is not to- 
be found in any modern work, treating of these 
subjects. Mr. Lennox Browne is to congratulated 
on having produced the best practical text-book 
on diseases of the throat and nose extant. We 
are glad to learn that it is being translated into 
French and German. — The Provincial Medical 
Journal, August 1, 1890. 



SELLER, CARL, M. I)., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. 
volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. 



Few medical writers surpass this author in 
ability to make his meaning perfectly clear in a 
few words, and in discrimination in selection, both 



of topics and methods. The book deserves a large 
sale, especially among general practitioners — C7ii- 
cago Medical Journal and Examiner, April, 1889. 



COHEN, J. SOLIS, M. L>., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 

GROSS, S. D., M.D., LL.D., JD.C.L. Oxon., LL.D. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. In one very hand- 
some octavo volume. 



JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS. Second 
American Edition. In one handsome octavo- 
volume of 340 pages. Cloth, $3.25. 



Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19 



one octavo 



MOSS, JAMBS, M.D., F.R. C.F., LL.D., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. In 

volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner. — Edinburgh MedicalJournal, Jan. 1887. 



MITCHELL, S. WEIR, M. I)., 

Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. 

Lectures on Diseases of the Nervous System; Especially in Women. 
INew (third) edition. In one 12mo. volume of about 300 pages. Preparing. 
A notice of the previous edition is appended. 



No work in our language develops or displays 
more features of that many-sided affection, hys- 
teria, or gives clearer directions for its differen- 
tiation, or sounder suggestions relative to its 
general management and treatment. The book 
is particularly valuable in that it represents in 
the main the author's own clinical studies, which 
have been so extensive and fruitful as to give his 



teachings the stamp of authority all over the 
realm of medicine. The work, although written 
by a specialist, has no exclusive character, and 
the general practitioner above all others will find 
its perusal profitable, since it deals with diseases 
which he frequently encounters and must essay 
to treat. — American Practitioner, August, 1885. 



HAMILTON, ALLAN McLAWE, M. I)., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackweWs Island, N. Y. 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 



When the first edition of this good book appeared 
we gave it our emphatic endorsement, and the 
present edition enhances our appreciation of the 
book and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



characterized this book as the best of its kind in 
any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old.— 
Alienist and Neurologist, April, 1882. 



TUKE, DANIEL HACK, M. L>., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. 

method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychol6gy. 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing.— New York Medical Journal, September 6, 1884. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomenathe more firmly 
has he adhered to a physiological and rational 



GRAY, LJlNJDON CARTER, M.I)., 

Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. 

A Practical Treatise on Diseases of the Nervous System. Preparing. 
CLOTJSTOIT, THOMAS S., M. D., F. R. C. JP., L. R. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Ch_rles F. Fo:lsom, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. 

The practitioner as well as the student will ac- the general practitioner in guiding him to a diag- 
cept the plain, practical teaching of the author as a nosis and indicating the treatment, especially in 
forward step in the literature of insanity. It is many obscure and doubtful cases of mental dis- 
refreshing to find a physician of Dr. Clouston's ease. To the American reader Dr. Folsom's Ap- 
experience and high reputation giving the bed- pendix adds greatly to the value of the work, and 
side notes upon which his experience has been will m-ke it a desirable addition to every library, 
founded and his mature judgment established. — A mencan Psychological Journal, July, 1884. 
Such clinical observations cannot but be useful to 

giSJPDr. Folsom's Abstract may also be obtained separately in one octavo volume of 
108 pages. Cloth, $1.50. 

SAVAGE, GEORGE H., M. JO., 

Lecturer on Mental Diseases at Guy's Hospital, London. 

Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. 
of 551 pages, with 18 illus. Cloth, $2.00. See Semes of Clinical Manuals, page 31. 

JPLATFAIR, W. S., M. D., F. R. C. JP. 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 



20 



Lea Brothers & Co.'s Publications — Surgery. 



ROBERTS, JOHN B., M. JD., 

Professor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Principles and 
Practice of Surgery in the Woman's Medical College of Pennsylvania. Lecturer in Anatomy in the Univer- 
sity of Pennsylvania. 

The Principles and Practice of Modern Surgery. For the use of Students 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of 780 
pages, with 501 illustrations. Cloth, $4.50; leather, $5.50. Just ready. 



This is another illustration of what can be done 
in these times to condense within proper limits 
the presentation of the best modern thought and 
experience covering important branches of medi- 
cal and surgical practice. The author has under- 
taken to prepare a practical statement of the best 
surgical methods and the approved surgical prin- 
ciples of the present day, and to the execution of 
this immense task he has brought the essentials of 
a ripe experience and a well trained judgment. It 
has been his object to sift the vast mass of material 
at hand and thus save his reader's time for the con- 
sideration only of matter pertinent to his purpose. 
The work is therefore one which may in the best 



and fullest sense be termed practical.— .Medical 
Age, Oct. 10, 1890. 

This book may be said to represent in a very 
thorough manner and hi a comparatively smali 
space the status of the surgery of the day. All the 
opinions expressed are sufficiently progressive 
to make the purchaser feel that in following the 
advice given he is doing all that the most carefully 
trained surgeon could do for his patient. The illus- 
trations, which are very frequent, are, like the 
text, up to date and unusually wel executed. If 
intrinsic value is the chief factor in making a book 
sell rapidly, Dr. Roberts' bx>k cannot fail to be 
a great success. — The Medical News, Oct. 18, 1890. 



ASJSBURST, JOHJST, Jr., M. J>., 

Barton Prof, of Surgery and Clin. Surgery in Univ. of Penna., Surgeon to the Penna. LTosp., etc. 

The Principles and Practice of Surgery. New (fifth) edition, enlarged 
and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with 
642 illustrations. Cloth, $6 ; leather, $7. 

This is one of the most popular and useful oS 
the many well-known treatises on general surgery. 
It furnishes in a concise manner a clear and 
comprehensive description of the modes of prac- 
tice now generally employed in the treatment of 
surgical affections, with a plain exposition of the 
principles on which those modes of practice are 
based. The entire work has been carefully revised, 
and a number of new illustrations introduced 
that greatly enhance the value of the book. — 
Cincinnati Lancet-Clinic, Dee. 14, 1889. 



A complete and most excellent work on surgery. 
It is only necessary to examine it to see at once 
its excellence and real merit either as text-book 
for the student or a guide for the general practi- 
tioner. It fully considers in detail every surgical 
injury and disease to which the body is liable, and 
every advance in surgery worth noting is to be 
found in its proper place. It is unquestionably the 
best and most complete single volume on surgery, 
in the English language, and cannot but receive 
that continued appreciation which its merits justly 
demand. — Southern Practitioner, Feb. 1890. 



DRJJ1TT, ROBERT, M. R. C. S., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
ley Boyd, M. B., B. S., F. K. C. S. In one 8vo. volume of 965 pages, with 373 illustra- 
tions. Cloth, $4 ; leather, $5. 



It is essentially a new book, rewritten from be- 
ginning to end. The editor has brought his work 
up to the latest date, and nearly every subject on 
which the student and practitioner would desire 
to consult a surgical volume, has found its place 
here. The volume closes with about twenty pages 
of formula? covering a broad range of practical 
therapeutics. The student will find that the new 
Druitt is to this generation what the old one was 
to the former, and no higher praise need be 
accorded to any volume.— North Carolina Medical 
Journal, October, 1887. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 
appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. — Cincinnati Medical 
News, September, 1887. 



GANT, FREDERICK JAMES, F. R. C. S., 

Senior Surgeon to the Royal Free Hospital. 
The Student's Surgery. A Multum in Parvo. In one square octavo volume 
of 848 pages, with 159 engravings. Cloth, $3.75. 



The claims of this volume to be a multum in 
parvo are certainly substantiated. The author 
covers the whole field of clinical and operative 
surgery in about eight hundred pages of very com- 
pactly printed matter. For a student's manual it 
appears to us in every way excellent, containing 
almost everything necessary to equip the student 
with sound, matter-of-fact knowledge on surgical 



subjects. The volume is a condensation of the 
author's well-known larger works on surgery, 
notably his " Science and Practice of Surgery ". 
Students requiring the essentials of surgery 
in a handy and condensed form, and those who 
cannot devote time to theoretical or speculative 
pathology will find this volume exceedingly ser- 
viceable. — The Physician and Surgeon, April, 1890. 



GROSS, S. n., M. D., LL. JD., 2>. C. L. Oxon., LL. D. 
Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15. 

BALL, CHARLES B., M. Ch., Duh., F. R. C. S., E., 

Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. 

Diseases of the Rectum and Anus. In one 12mo. volume of 417 pp., 
with 54 cuts, and 4 colored plates. Cloth, $2.25. See Series of Clinical Manuals 31. 

GIBNEY, V. P., M7n., 



Surgeon to the Orthopaedic Hospital, New York, etc. 

Orthopaedic Surgery. For the use of Practitioners and Students, 
some octavo volume, profusely illustrated. Preparing. 



In one hand- 



Lea Brothers & Co.'s Publications — Surgery. 



21 



EBICH8EN, JOHN E., F. B. S., F. B. C. 8., 

Professor of Surgery in University College, London, etc. 
The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 
beautiful octavo volumes of 2316 pages, 
Cloth, $9; leather, raised bands, $11. 

We have always regarded "The Science and 
Art of Surgery" as one of the best surgical text- 
books in the English language, and this eighth 
edition only confirms our previous opinion. We 
take great pleasure in cordially commending it to 
our readers. — The Medical News, April 11, 1885. 

For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 
through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 
of the former edition has been dropped and no 
discovery, device or improvement which has 



illustrated with 984 engravings on wood. 



marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
— Louisville Medical News, Feb. 14, 1885. 

We cannot speak too highly of this excellent 
work. It represents the most advanced and settled 
views in regard to the science of surgery, and will 
ever be found a faithful guide and counsellor in 
practice. — Canada Lancet, May, 1885. 

It appears simultaneously in England, America, 
Spain and Italy, and is too well known as a safe 
guide and familiar friend to need further com- 
ment.— New York Medical Journal, March 28, 1885v 



BBYANT, THOMAS, F. B. C. 8., 

Surgeon and Lecturer on Surgery at Guy's Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50; leather, $7.50. 



The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 
place the work among the highest order of text- 
books for the medical student. Almost every 
topic in surgery is presented in such a form as to 



enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is- 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical. — Chicago Medical Journal and Examiner, 
April, 1886. 

This book is essentially what it purports to be, 
viz.: a manual for the practice of surgery. It i» 
peculiarly well fitted for the student or busy general 
practitioner.— The Medical News, August 15, 1885. 



TBEVE8, FBEDEBICK, F. B. C. 8., 

Hunterian Professor at the Royal College of Surgeons of England. 
A Manual of Surgery. In Treatises by Various Authors. In three 12mo. 
volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See 
Students' Series of Manuals, page 31. 



We have here the opinions of thirty-three 
authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance.— Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



MABSH, HOWABJD, F. B. C. $., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. 

Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts- 
and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 31. 

BUT LIN, HENBY T., F. B. C. 8., 

Assistant Surgeon to St. Bartholomew's Hospital, London. 

Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored 
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 31. 

veniently scattered through general works on sur- 



The language of the text is clear and concise. 
The author has aimed to state facts rather than to 
express opinions, and has compressed within the 
compass of this small volume the pathology, etiol- 
ogy, etc., of diseases of the tongue that are incon- 



gery and the practice of medicine. The physician 
and surgeon will appreciate its value as an aid and 
guide. — Physician and Surgeon, Sept. 1886. 



TBEVES, FBEDEBICK, F. B. C. S., 

Surgeon to and Lecturer on Surgery at the London Hospital. 

Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 
illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 31. 



A standard work on a subject that has not been 
so comprehensively treated by any contemporary 
English writer. Its completeness renders a full 
review difficult, since every chapter deserves mi- 



justice to the author in a few paragraphs. Intes- 
tinal Obstruction is a work that will prove of 
equal value to the practitioner, the student, the 
pathologist, the physician and the operating sur- 



nute attention, and it is impossible to do thorough geon. — British Medical Journal, Jan. 31, 1885, 

GOULD, A. FEABCE, M. 8., M. B., F. B. C. 8., 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589> 
pages. Cloth, $2.00. See Students' Series of Manuals, page 31. 

PIRRIE'S PRINCIPLES AND PRACTICE OF one 8vo. vol. of 638 pages, with 340 illustrations. 

SURGERY. Edited by John Neill, M. D. In Cloth, $3.75. 

oneSvo.vol. of 784 pp. with 316 illus. Cloth, $3.75. MILLER'S PRACTICE OF SURGERY. Fourth 

MILLER'S PRINCIPLES OF SURGERY. Fourth and revised American edition. In one large 8vo. 

American from the third Edinburgh edition. In vol. of 682 pp., with 364 illustrations. Cloth, $3.75. 



22 Lea Brothers & Co.'s Publications — Surgery* Frac, Disloc. 



SMITH, STEPHEN, M. D., 

Professor of Clinical Surgery in the University of the City of New York. 

The Principles and Practice of Operative Surgery. New (second) and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 
1005 illustrations. Cloth, $4 00; leather, $5.00. 

This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. Its author and publisher 
have spared no pains to make it as far as possible 
an ideal, and their efforts have given it a position 



prominent among the recent works in this depart- 
ment of surgery. The book is a compendium for 
<the modern surgeon. The present, the only revised 
edition since 1879, presents many changes from 
the original manual. The volume is much en- 
larged, and the text has been thoroughly revised, 
«o as to give the most improved methods in asep- 



tic surgery, and the latest instruments known for 
operative work. It can be truly said that as a hand- 
book for the student, a companion for the surgeon, 
and even as a book of reference for the physician 
not especially engaged in the practice or surgery, 
this volume will long hold a most conspicuous 
place, and seldom will its readers, no matter how 
unusual the subject, consult its pages in vain. Its 
compact form, excellent print, numerous illustra- 
tions, and especially its decidedly practical char- 
acter, all combine to commend it.— Boston Medical 
and Surgical Journal, May 10, 1888. 



HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A Treatise on Surgery; Its Principles and Practice. New American 
from the fifth English edition, edited by T. Pickering Pick, F,. E. C. S., Surgeon and 
Lecturer on Surgery at St. George's Hospital, London In one octavo volume of 997 
pages, with 428 illustrations. Cloth, $6 ; leather, $7. 



To the younger members of the profession and 
>to others not acquainted with the book and its 
merits, we take pleasure in recommending it as a 
surgery complete, thorough, well-written, fully 
'illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



for the general practitioner, teaching those things 
that are necessary to be known for the successful 
prosecution of the physician's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient.— Pacific 
Medical Journal, July, 1889. 



HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TKEATISES BY 
VAEIOUS AUTHOBS. American edition, thoroughly revised and re-edited 
'by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large imperial octavo volumes containing 3137 double- columned pages, with 
■979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per 
set, cloth, $18.00 ; leather, $21.00. Sold only by subscription. 

STIMSON, LEWIS A., B. A., M. JO., 

Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical 
Faculty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgie of Paris. 
A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50* 



There is always room for a good book, so that 
•while many works on operative surgery must be 
considered superfluous, that of Dr. Stimson has 
held its own. The author knows the difficult art 
<©f condensation. Thus the manual serves as a 
work of reference, and at the same time as a 
handy guide. It teaches what it professes, the 
:3teps of operations. In this edition Dr. Stimson 
has sought to indicate the changes that have been 



effected in operative methods and procedures by 
the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation. — British Medical Journal, Jan. 22, 1887. 



By the same Author. 
^^A Treatise on Fractures and Dislocations. In two handsome octavo vol- 
umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- 
tions, 540 pages, with 163 illustrations. Complete work, cloth, $5.50 ; leather, $7.50. 
Either volume separately, cloth, $3.00 ; leather, $4.00. 



The appearance ofthe second volume marks the 
completion ofthe author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. The closing 
volume of Dr. Stimson's work exhibits the surgery 



of Dislocations as it is taught and practised by the 
most eminent surgeons of the present time. Con- 
taining the results of such extended researches it 
must for a long time be regarded as an authority 
on all subjects pertaining to dislocations. Every 

Eractitioner of surgery will feel it incumbent on 
im to have it for constant reference. — Cincinnati 
Medical News, May, 1888. 



HAMILTON, FJRANK H., M. I)., LL. 2>., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition 
thoroughly revised and much improved. In one very handsome octavo volume of 998 
pages, with 379 illustrations. Cloth, $5.50 ; leather, $6.50. 

PICK, T. PICKEHIJSTG, F. It. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume of 530 pages, with 93 
illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 31. 



WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 



LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS : Their Immediate and Remote 
Effects. In one octavo volume of 404 pages, with 
92 illustrations. Cloth, $3.50. 



Lea Brothers & Co.'s Publications — Otol., Ophthal. 23> 

BVRNETT, C SABLES JEE., A. M., M. &., 

Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. Second edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

We note with pleasure the appearance of a second carried out, and much new matter added. Dr~ 
edition of this valuable work. When it first came Burnett's work must be regarded as a very valua- 
out it was accepted by the profession as one of ble contribution to aural surgery, not only on. 
the standard works on modern aural surgery in account of its comprehensiveness, but because it 
the English language; and in his second edition contains the results of the careful personal observa- 
Dr. Burnett has fully maintained his reputation, tion and experience of this eminent aural surgeon., 
for the book is replete with valuable information —London Lancet, Feb. 21, 1885. 
and suggestions. The revision has been carefully 



JPOLITZEB, ADAM, 

Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna. 

A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Casseles, M. D., M. E. C. S. In one handsome octavo vol- 
ame of 800 pages, with 257 original illustrations. Cloth, $5.50. 

The whole work can be recommended as a reli- I the practitioner in his treatment. — Boston Medica I 
able guide to the student, and an efficient aid to | and Surgical Journal, June 7, 1883. 



BEBBY, GEORGE A., M. B., F. B. C. S., Ed., 

Ophthalmic Surgeon, Edinburgh Royal Infirmary. 
Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. In- 
one octavo volume of 683 pages, with 144 illustrations, 62 of which are beautifully 
colored. Cloth, $7.50. 



This newest candidate for favor among ophthal- 
mological students is designed to be purely clinical 
in character and the plan is well adhered to. We 
have been forcibly struck by the rare good taste 
in the selection of what is essential which per- 
vades the book. The author seems to have the 
uncommon faculty of viewing his subject as a 
whole and seizing the salient points and not con- 
fusing his reader — presumably a student and a 



novice — with a mass of details with no key to their 
unravelling. It is apparent that the literature of 
each subject has been gone over in a very thor- 
ough manner. The fact that he was writing & 
clinical treatise for beginners and not an encyclo- 
paedia has always been present with the author. 
The number and excellence of the colored illus- 
trations in the text deserve more than a passing; 
notice. — Archives of Ophthalmology, Sept. 1889. 



JTJEEB, sejvbt e., f. b. c. s., 

Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp.; late Clinical Ass't, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. Handsome 870. vol- 
ume of 460 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of 
Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; leather, $5.50. 

illustrations are nearly all original. We have ex- 
amined this entire work with great care, and it 



It presents to the student concise descriptions 
and typical illustrations of all important eye affec- 



tions, placed in juxtaposition, so as to be grasped 
at a glance. Beyond a doubt it is the best illus- 
trated handbook of ophthalmic science which has 
ever appeared. Then, what is still better, these 



represents the commonly accepted views of ad- 
vanced ophthalmologists. We can most heartily 
commend this book to all medical students, prac- 
titioners and specialists. — Detroit Lancet, Jan. '85. 



nettleship, ei>warjd, e. b. c. s., 

Ophthalmic Surgeon at St. Thomas'' Hospital, London. Surgeon to the Royal London (Moorfields} 
Ophthalmic Hospital. 

Diseases of the Eye. New (fourth) American from the fifth English edition, 
thoroughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. 
In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test- 
types and formulae, and a colored plate. Cloth, $2.00. Just ready. 

This work, known in former editions as The Students' Guide to Diseases of the Eye, has- 
now been increased in scope and its title has been commensurately broadened. It will 
continue to be a widely prescribed text-book, and the enlargement above noted will render 
it more than ever a favorite among practitioners, who have valued it for the practical 
nature of its contents. 



NOBBIS, WM. F., M. D., and OLIVEB, CJSAS. A., M. D» 

Clin. Prof, of Ophthalmology in Univ. of Pa. 

A Text-Book of Ophthalmology. In one octavo volume of about 500 pages,, 
with illustrations. Preparing. 



CABTEB, B. BBUDEJSTELL, & FBOST, W.ADAMS, 

F. B. C. S., F. B. C. S.? 

Ophthalmic Surgeon to and Led. on Ophthalr- AssH Ophthalmic Surgeon and Joint Led. 

mic Surgery at St. George's Hospital, London. on Oph. Sur., St. George's Hosp., London. 

Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, 
color-blindness test, test-types and dots and appendix of formulae. Cloth, $2.25. See 
Series of Clinical Manuals, page 31. 



'24: Lea Brothers & Co.'s Publications — Urin. Dis., Dentistry, etc. 



ROBERTS, WILLIAM, M. I)., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In One hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, f 3.50. 



It may be said to be the best book in print on the 
subject of which it treats. — The American Journal 
of the Medical Sciences, Jan. 1886. 

The peculiar value and finish of the book are in 
a measure derived from its resolute maintenance 
of a clinical and practical character. It is an un- 
rivalled exposition of everything which relates 
directly or indirectly to the diagnosis, prognosis 
and treatment of urinary diseases, and possesses 
a completeness not found elsewhere in our lan- 



guage in its account of the different affections.— 
The Manchester Medical Chronicle, July, 1885. 

The value of this treatise as a guide book to the 
physician in daily practice can hardly be over- 
estimated. That it is fully up to the level of our 
present knowledge is a fact reflecting great credit 
upon Dr. Roberts, who has a wide reputation as a 
busy practitioner. — The Medical Record, July 31, 
1886. 



FVRDY, CHARLES W., M. I)., Chicago. 

Bright's Disease and Allied Affections of the Kidneys. In one octavo 
volume of 288 pages, with illustrations. Cloth, $2. 



The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 
1886. 



MORRIS, HENRY, M. B., F. R. C. 8., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31. 



In this manual we have a distinct addition to 
surgical literature, which gives information not 
-elsewhere to be met with in a single work. Such 
a book was distinctly required, and Mr. Morris 
has very diligently and ably performed the task 



he took in hand. It is a full and trustworthy 
book of reference, both for students and prac- 
titioners in search of guidance. The illustrations 
in the text and the chromo-lithographs are beau- 
tifully executed.— The London Lancet,Feb. 26, 1886. 



See Series 



LUCAS, CLEMENT, M. B., B. S., E. R. C. S., 

Senior Assistant Surgeon to Ghiy's Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. 
■of Clinical Manuals, page 4. 

THOMPSON, SIR HENRY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMERICAN SYSTEM OF DENTISTRY. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by 
subscription only. 

doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it— they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while the profession at large 
will receive incalculable benefit from it. — Odonto- 
graphy Journal, Jan. 1887. 



As an encyclopaedia of Dentistry it has no su- 

f>erior. It should form a part of every dentist's 
ibrary, as the information it contains is of the 
freatest value to all engaged in the practice of 
entistry. — American Jour. Dent. Sci., Sept. 1886. 
A grand system, big enough and good enough 
and handsome enough for a monument (which 



COLEMAN, A., L. R. C. F., F. R. C. S., Exam. L. I>. S., 

Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Steklwagen, M. A., M. D., 
D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

The author brings to his task a large experience 
acquired under the most favorable circumstances. 
There have been added to the volume a hundred 
pages by the American editor, embodying the 
views of the leading home teachers in dental sur- 
gery. The work, therefore, may be regarded as 
strictly abreast of the times, and as a very high 
authority on the subjects of which it treats. — 
American Practitioner, July, 1882. 



It should be in the possession of every practi- 
tioner in this country. The part devoted to first 
and second dentition and irregularities in the per- 
manent teeth is fully worth the price. In fact, 
price should not be considered in purchasing such 
a work. If the money put into some of our so- 
called standard text-books could be converted into 
such publications as this, much good would result. 
—Southern Dental Journal, May, 1882. 



BASHAM ON RENAL DISEASES : A Clinical 
Guide to their Diagnosis and Treatment. In 



one 12mo. vol. of 304 pages, with 21 illustrations. 

Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 



25 



GBOSS, SAMUEL W., A. M., M. L>., XX. !>., 

Professor of the Principles of Surgery arid of Clinical Surgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. New (4th) edition, thoroughly revised by F. K. 
Stubgis, M. D., Prof, of Diseases of the Genito- Urinary Organs and of Venereal Diseases,, 
N. Y. Post Grad. Med. School. In one very handsome octavo volume of 165 pages,, 
with 18 illustrations. Cloth, $1.50. Just ready. 

A few notices of the previous edition are appended. 



It must be gratifying to both author and pub- 
lishers that large first and second editions of this 
little work were so soon exhausted, while the fact 
that it has been translated into Russian may indi- 
cate that it filled a void even in foreign literature. 
His is a careful and physiological study of the 
sexual act, so far as concerns the male, and all 
his conclusions are scientifically reached. The 
book has a place by itself in our literature, and 
furnishes a large fund of information concerning 



important matters that are too often passed over 
in silence. — The Medical Press, June, 1887. 

This now classical work on the subject of impo- 
tence and sterility in the male needs no extended 
review, for it is already well known to the pro- 
fession. Dr. Gross has by his tireless labor done 
more towards clearing up the diagnosis and treat- 
mentof these obscure cases than any other Ameri- 
can physician.— Atlanta Medical and Surgical Jour- 
nal, April, 1888. 



TAYLOR, B. W., A. M., M. D., 

Clinical Professor of Genito- Urinary Diseases in the College of Physicians and Surgeons-, New York* 
Prof, of Venereal and Skin Diseases in the University of Vermont, 

The Pathology and Treatment of Venereal Diseases. Including the- 
results of recent investigations upon the subject. Being the sixth edition of Bumstead 
and Taylor. Entirely rewritten by Dr. Taylor. Large 8vo. volume, about 900 pages,. 
with about 150 engravings, as well as numerous chromo-lithographs. In active preparation. 
A few notices of the previous edition are appended. 

known that it would be superfluous here to pass h* 
review its general or special points of excellence. 
The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 
plete exposition of the pathology and treatment of 
venereal diseases in the language. Admirable as & 
model of clear description, an exponent of soundi 
pathological doctrine, and a guide for rational and 
successful treatment, itis an ornament to the medi- 
cal literature of this country. The additions made 
to the present edition are eminently judicious,, 
from the standpoint of practical utility. — Journal of 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 
upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
tnemes. — Am. Jour, of the Med. Sciences, Jan. 1884. 

It is certainly the best single treatise on vene- 
real in our own, and probably the best in any lan- 
guage. — Boston Med. and Surg. Journal, April 3, 1884. 

The character of this standard work is so well 



ip< 

Cutaneous and Venereal Diseases, Jan. 1884. 



cobjvil, r. 9 

Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. SiMESy 
M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. William 
White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one handsome octavo 
volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 

The anatomy, the histology, the pathology and I perusal without the feeling that his grasp of the- 
the clinical features of syphilis are represented in wide and important subject on which it treats i&< 
this work in their best, most practical and most a stronger and surer one. — The London Practx- 
instructive form, and no one will rise from its tioner, Jan. 1882. 



HUTCHINSON, JONATHAN, F. B. S., F. B. C. S., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. Clothe 
$2.25. See Series of Clinical Manuals, page 31. 

Those who have seen most of the disease and 
those who have felt the real difficulties of diagno- 



sis and treatment will most highly appreciate the 
facts and suggestions which abound in these 
pages. It is a worthy and valuable record, not 
only of Mr. Hutchinson's very large experience 



and power of observation, but of his patience and' 
assiduity in taking noies of his cases and keep- 
ing them in a form available for such excellent 
use as he has put them to in this volume. — London' 
Medical Record, Nov. 12, 1887. 



GBOSS, s. n., M. n., LL. l>., n. C. L. 9 etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Thirdf 
edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 57 £ 
pages, with 170 illustrations. Cloth, $4.50. 

CULLFBIFB, A., & BUMSTFAD, F. J., M.I)., LL.D., 

Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physicians 
and Surgeons, New York. 

An Atlas of Venereal Diseases. Translated and edited by Freeman J. Busa- 
stead, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates., 
containing about 150 figures, beautifully colored, many of them the size of life. Strongly- 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts>. 



HILL ON SYPHILIS AND LOCAL CONTAGIOUS 

DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. 

LEE'S LECTURES ON SYPHILIS AND SOME 



FORMS OF LOCAL DISEASE AFFECTING 
PRINCIPALLY THE ORGANS OF GENERA- 
TION. In one 8vo. vol. of 246 pages. Cloth, $2.2c>. 



26 



Lea Brothers & Co.'s Publications — Venereal, Skin. 



TAYLOR, ROBERT W., A.M., M.D., 

Clinical Professor of Qenifo Urinarv Diseases in the College of Physicians and Surgeons, New York'; 
Surgeon to the Department of Venereal and Skin Diseases of the New Fork Hospital; Presi- 
dent of the American Dermatologtcal Association. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and 
comprising 58 beautifully-colored plates with 213 figures, and 431 pages of text with 85 
<engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, 
half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 



The completion of this monumental work is a 
subject of congratulation, not only to the author 
sand publishers, but to the profession at large; 
indeed it is to the latter that it directly appeals as 
ra wonderfully clear exposition of a confessedly 
difficult branch of medicine. Good literature has 
joined hands with good art with highly satisfac- 
tory results for both. There are altogether 213 
^figures, many of which are life size, and represent 
the highest perfection of the chromo-litho- 
graphic art, and scattered throughout the text are 
innumerable engravings. Quite a proportion of 
•these illustrations are from the author's own 
collection, while on the other hand the best 
.atlases of the world have been drawn upon for 
the most typical and successful pictures of the 
■many different types of venereal and skin dis 
-ease. We think we may say without undue 
exaggeration that the reproductions, both in color 
and in black and white, are almost invariably 
^successful. The text is practical, full of thera- 
peutical suggestions, and the clinical accounts of 
disease are clear and incisive. Dr. Taylor is, 
happily, an eminent authority in both departments, 
and we find as a consequence that the two divis- 
ions of this work possess an equal scientific and 
literary merit. We have already passed the limits 



allotted to a notice of this kind, and while we 
have nothing but praise for this admirable atlas, 
it must be said in justification that it is more than 
warranted by the merits of the work itself. — 
The Medical News, Dec. 14, 1889. 

It would be hard to use words which would per- 
spicuously enough convey to the reader the great 
value of this Clinical Atlas. This Atlas is more 
complete even than an ordinary course of clinical 
lectures, for in no one college or hospital course 
is it at all probable that all of the diseases herein 
represented would be seen. It is also more ser- 
viceable to the majority of students than attend- 
ance upon clinical lectures, for most of the 
students who sit on remote seats in the lecture 
hall cannot see the subject as well as the office 
student can examine these true to-life chromo-lith- 
ographs. Comparing the text to a lecturer, it is 
more satisfactory in exactness and fulness than 
he would be likely to be in lecturing over a single 
case. Indeed, this Atlas is invaluable to the gen- 
eral practitioner, for it enables the eye of the 
physician to make diagnosis of a given case of 
skin manifestation by comparing the case with 
the picture in the Atlas, where will be found also 
the text of diagnosis, pathology, and full sections 
on treatment.— Virginia Medical Monthly, Dec. 1889. 



HYDE, J. NEVUSTS, A. M., M. D., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, 
with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. 



We can heartily commend it, not only as an 
admirable text-book for teacher and student, but 
in its clear and comprehensive rules for diagnosis, 
its sound and independent doctrines in pathology, 
and its minute and judicious directions for the 
treatment of disease, as a most satisfactory and 
-complete practical guide for the physician. — Ameri- 
can Journal of the Medical Sciences, July, 1888. 

A useful glossary descriptive of terms is given. 
The descriptive portions of this work are plain 
and easily understood, and above all are very 
accurate. The therapeutical part is abundantly 
supplied with excellent recommendations. The 
picture part is well done. The value of the work 
to practitioners is great because of the excellence 
of the descriptions, the suggestiveness of the 
advice, and the correctness of the details and the 
principles of therapeutics impressed upon the 
■reader. — Virginia Med. Monthly, May, 1888. 



The second edition of his treatise is like his 
clinical instruction, admirably arranged, attractive 
in diction, and strikingly practical throughout. 
The chapter on general symptomatology is a model 
in its way ; no clearer description of the various 

Erimary and consecutive lesions of the skin is to 
e met with anywhere. Those on general diagno- 
sis and therapeutics are also worthy of careful 
study. Dr. Hyde has shown himself a compre- 
hensive reader of the latest literature, and has in- 
corporated into his book all the best of that which 
the past years have brought forth. The prescrip- 
tions and formulae are given in both common and 
metric systems. Text and illustrations are good, 
and colored plates of rare cases lend additional 
attractions. Altogether it is a work exactly fitted 
to the needs of a general practitioner, and no one 
will make a mistake in purchasing it.— Medical 
Press of Western New York, June, 1888. 



FOX, T., M. D., F.R. C. P., and FOX, T. C, B.A., M.R. C.S., 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $1.25. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
•one which we can strongly recommend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology. — British Medical Journal, July 2, 1883. 

We cordially recommend Fox's Epitome to those 
■whose time is limited and who wish a handy 



manual to lie upon the table for Instant reference. 
Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented.— The Medical News, December, 1883. 



WILSON, ERASMUS, F. R. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

I n one handsome small octavo volume of 535 pages. Cloth, $3.50. 



SILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 



can edition. In one 12mo. volume of 353 pages, 

with plates. Cloth, $2.25. 



Lea Brothers & Co.'s Publications — Dis. of Women. 



2T 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics- 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work just ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Eussia, $7.00. For sale by subscription only.. 
Address the Publishers. Full descriptive circular free on application. 

LIST OF CONTRIBUTORS. 

CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., LL. D., 
J. HENDRIE LLOYD, M. D., 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M. D^ 

D.Sc, M.A., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D., LL. D., 
R. A. F. PENROSE, M. D., LL. D., 
THADDEUS A. REAMY, A. M., M. D., 
J. C. REEVE, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
STEPHEN SMITH, M. D., 
R. STANSBURY SUTTON, A.M., M. D.,„ 

LL. D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE, M. D. 
tor may be congratulated for having made such a 
wise selection of his contributors. — Journal of the 
American Medical Association, Sept. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement:— "It is a work of which the pro- 
fession in this country can feel proud. Written, 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one- 
of them would desire to have it." Every word' 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the- 
"System of Gynecology by American Authors," 
which we desire now to bring to the attention of 
our readers. It, like the other, has been written 
exclusively by American physicians who are 
acquainted with all the characteristics of American 
people, who are well informed in regard to the- 
peculiarities of American women, their manners, 
customs, modes of living, etc. As every practis- 
ing physician is called upon to treat diseases of 
females, and as they constitute a class to which 
the family physician must give attention, and 
cannot pass over to a specialist, we do not know of 
a work in any department of medicine that we- 
should so strongly recommend medical men gen- 
erally purchasing.— Cincinnati Med. News, July ,1887=. 



WILLIAM H. BAKER, M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D., 
JAMES C. CAMERON, M. D., 
HENRY C. COE, A. M., M. D., 
EDWARD P. DAVIS, M. D., 
G. E. De SCHWEINITZ, M. D m 
E. C. DUDLEY, A. B., M. D., 
B. McE. EMMET, M. D., 
GEORGE J. ENGELMANN, M. D., 
HENRY J. GARRIGUES, A. M., M. D., 
WILLIAM GOODELL, A. M., M. D., 
EGBERT H. GRANDIN, A. M., M. D., 
SAMUEL W. GROSS, M. D., 
ROBERT P. HARRIS, M. D., 
GEORGE T. HARRISON, M. D., 
BARTON C. HIRST, M. D. 
STEPHEN Y. HOWELL, M. D., 
A. REEVES JACKSON, A. M., M. D., 
W. W. JAGGARD, M. D., 
EDWARD W. JENKS, M. D., LL. D., 
HOWARD A. KELLY, M. D., 
This is volume two of The American System of 
Obstetrics, completing the wonderfully full series 
issued from the house of Lea Brothers & Co. dur- 
ing the past two years. Two magnificent volumes 
devoted to gynecology, and now two like volumes 
embracing everything pertaining to obstetrics. 
These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor 
presents a monograph upon his special topic, 
apparently without restriction in space, so that 
everything in the way of history, theory, methods, 
and results is presented to our fullest need. The 
work will long remain as a monument of great in- 
dustry and good judgment. As a work of general 
reference, it will be found remarkably full and in- 
structive in ever*y direction of inquiry. — The Ob- 
stetric Gazette, September, 1889. 

There can be but little doubt that this work will 
find the same favor with the profession that has 
been accorded to the "System of Medicine by 
American Authors," and the "System of Gynecol- 
ogy byAmerican Authors." One is at a loss to know 
wnat to say of this volume, for fear that just and 
merited praise may be mistaken for flattery. The 
subjects of some of the papers are discussed in 
various works on obstetrics, though not to the full 
extent that Is found in this volume. The papers 
of Drs. Engelmann, Martin, Hirst, Jaggard and 
Reeve are incomparably beyond anything that can 
be found in obstetrical works. Certainly the Edi- 



THOMAS, T. GAILLAItJD, M. L>., LL. I>., 

Professor of Diseases of Women in the College of Physic ians and Surgeons, N. T. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266> 
illustrations. Cloth, $5.00 ; leather, $6.00. 

That the previous editions of the treatise of Dr. 
Thomas were thought worthy of translation into 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit. At home it 
has made its way into the library of every obste- 



trician and gynaecologist as a safe guide to practice^ 
No small number of additions have been made tc- 
the present edition to make it correspond to re- 
cent improvements in treatment. — Pacific Medical 
and Surgical Journal, Jan. 1881. 



EDIS, ABTJBCUB W., M. D., Lond., F.M. C.B., M.JR. C.S.,. 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms,, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome- 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 



It is a pleasure to read a boofe so thoroughly 
good as this one. The special qualities which are 
conspicuous are thoroughness in covering the 
whole ground, clearness of description and con- 
ciseness of statement. Another marked feature of 
the book is the attention paid to the details of 
many minor surgical operations and procedures, 
as, for instance, the use of tents, application of 
leeches, and use of hot water injections. These 



are among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be- 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too > 
will find many useful hints in its pages.— Bostor> 
Med. and Surg. Journ., March 2, 1882. 



28 Lea Brothers & Co.'s Publications— Dis. of Women, Midwfy. 



EMMET, THOMAS ADDIS, M. !>., LL. !>., 

Surgeon to the Woman's Hospital, New York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; 
very handsome half Russia, raised bands, $6.50. 



We are in doubt whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 
Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
■as a bold and successful operator, and who has 
•devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 



the privilege thus offered them of perusing the 
views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gynae- 
cological science and art. — British Medical Jour- 
nal, May 16, 1885. 



TAIT, LAWSOJST, F.B. C. S., 

Professor of Oynoecology in Queen's College, Birmingham; late President of the British Gyne- 
cological Society ; Fellow American Gynecological Society. 

Diseases of "Women and Abdominal Surgery. In two very handsome 
•octavo volumes. Volume I., 554 pages, 62 engravings and 3 plates. Cloth, $3. Now 
Volume II., preparing. 

Much of the text is abundantly illustrated with 
cases, which add value in showing the results of 
the suggested plans of treatment. We feel con- 
fident that few gynecologists of the country will 
fail to place the work in their libraries. — The 
Obstetric Gazette, March, 1890. 



The plan of the work does not indicate the regu- 
lar system of a text book, and yet nearly every- 
thing of disease pertaining to the various organs 
receives a fair consideration. The description of 
•diseased conditions is exceedingly clear, and the 
treatment, medical or surgical, is very satisfactory. 



DAVENPOBT, F. H., M. L>., 

Assistant in Gynaecology in the Medical Department of Harvard University, Boston. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. De- 
signed especially for the Use of Students and General Practitioners. In one handsome 
!2mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. Just ready. 



We agree with the many reviewers whose no- 
tices we have read in other journals congratulating 
Dr. Davenport on the success which he has 
attained. He has tried to write a book for the 
student and general practitioner which would 
tell them just what they ought to know without 
distracting their attention with a lot of compila- 
tions for which they could have no possible use. 
In this he has been eminently successful. There 
is not even a paragraph of useless matter. 



Everything is of the newest, freshest and most 
practical, so much so that we nave recommended 
it to our class of gynecology students. What the 
author advises in the way of treatment has all 
been practically tested by himself, and each 
method receives only so much commendation as he 
has found that it deserves. We are sure that 
these good qualities will command for it a large 
sale.— Canada Medical Record, Dec. 1889. 



MAY, CHABLES JL., M. JD., 

Late House Surgeon to Mount Sinai Hospital, New York. 
A Manual Of theDiseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynecology. New (2d) edition, edited by L. S. Eau, 
M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. volume of 
360 pages, with 31 illustrations. Cloth, $1.75. Just ready. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
■3, favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
(practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily. — The Physician and 
Surgeon, June, 1890. 



nVNCAJT, J. MATTHEWS, M.D., LL. JD., F. B. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

They are in every way worthy of their author ; rule, adequately handled in the textbooks ; others 
indeed, we look upon them as among the most of them, while bearing upon topics that are usually 
valuable of his contributions. They are all upon treated of at length in such works, yet bear such a 
^matters of great interest to the general practitioner, stamp of individuality that they deserve to be 
Some of them deal with subjects that are not, as a widely read.— N. Y. Medical Journal, March, 1880. 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Incl uding Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $4.50. 

BAMSBOTHAM'S PRINCIPLES AND PRAC- 
TICE OP OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised by the Author. With additions 
by W. V. Keating, M. D., Professor of Obstetrics, 



etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full page 
plates and 43 woodcuts in the text, containing in 
all nearly 200 beautiful figures. Strongly bound 
in leather, with raised bands, $7. 
WEST'S LECTURES ON THE DISEASES OF 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. 
Cloth, $3.75; leather, $4.75. 



Lea Brothers & Co.'s Publications — Midwifery. 



29 



BABVIN, THFOBJBCILUS, M. !>., LL. &., 

Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. 
The Science and Art of Obstetrics. New (2d) edition. In one handsome 
8vo. volume of 701 pages, with 239 engravings and a colored plate. Cloth, $4.25 ; leather, 
$5.25. Just ready. 



This, the second, edition has been thoroughly- 
revised, and possesses the advantage that the 
essential facts are fully presented, free from con 



himself as to the advances in the art. The busy 
practitioner of to-day wants practical, condensed, 
utilizable knowledge of facts. We are glad to see 



fusing and unnecessary verbiage. This must a book meeting this demand, as it must lead to a 



make it an eligible book for students, and will 
explain its popularity as a textbook and for refer- 
ence bv the practitioner who desires to inform 



larger purchase of new works by physicians who 
desire completa libraries at moderate cost. — The 
Medical Age, October 10, 1890. 



blayfaib, w. s., m. l>., f. b. a b., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fifth) 
American, from the seventh English edition. Edited, with additions, by Robert P. Har- 
ris, M. D. In one handsome octavo volume of 664 pages, with 207 engravings and 5 
plates. Cloth, $4.00 ; leather, $5.00. Just ready. 

Truly a wonderful book ; an epitome of all ob- 
stetrical knowledge, full, clear and concise. In 
thirteen years it has reached seven editions. It 
is perhaps the most popular work of its kind ever 
presented to the profession. Beginning with the 
anatomy and physiology of the organs concerned, 
nothing is left unwritten that the practical ac- 
coucheur should know. It seems that every 
conceivable physiological or pathological condi- 



tion from the moment of conception to the time 
of complete involution has had the author's 
patient attention. The plates and illustrations, 
carefully studied, will teach the science of mid- 
wifery. The reader of this book will have before 
him the very latest and best of obstetric practice, 
and also of all the coincident troubles connected 
therewith.— Southern Practitioner, Dec, 1889. 



KING, A. F. A., M. JD., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- 
sity, Washington, D. C, and in the University of Vermont, etc. 

A Manual of Obstetrics. New (fourth) edition. In one very handsome 12mo. 
volume of 432 pages, with 140 illustrations. Cloth, $2.50. 

Dr. King, in the preface to the first edition of 
this manual, modestly states that "its purpose is 
to furnish a good groundwork to the student at 
the beginning of his obstetric studies." Its pur- 
pose is attained ; it will furnish a good ground- 
work to the student who carefully reads it; and 
further, the busy practitioner should not scorn the 
volume because written for students, as it eon- 
tains much valuable obstetric knowledge, some 
of which is not found in more elaborate text- 
books. The chapters on the anatomy of the 
female generative organs, menstruation, fecunda- 
tion, the signs of pregnancy, and the diseases of | cal News, Dec." 7 
pregnancy, are all excellent and clear ; but it is in ' 



the description of labor, both normal and abnor- 
mal, that Dr. King is at his best. Here his style 
is so concise, and the illustrations are so good, 
that the veriest tyro could not fail to receive a clear 
conception of labor, its complications and treat- 
ment. Of the 141 illustrations it may be safely 
said that they all illustrate, and that the engraver's 
work is excellent. The name of the publishers 
is a sufficient guarantee that the work is pre- 
sented in an attractive form, and from every 
standpoint we can most heartily recommend the 
book both to practitioner and student. — The MedU 



BARNES, BOBFBT, M. JO., and FANCOUBT, M.I)., 

Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' Hosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 



The immediate purpose of the work is to furnish 
■3, handbook of obstetric medicine and surgery 
for the use of the student and practitioner. It is 
not an exaggeration to say of the book that it is 
the best treatise in the English language yet 
published, and this will not be a surprise to those 
who are acquainted with the work of the elder 
Barnes. Every practitioner who desires to have 



the best obstetrical opinions of the time in a 
readily accessible and condensed form, ought to 
own a copy of the book.— Journal of the American 
Medical Association, June 12, 1886. 

The Authors have made a text-book which is in 
every way quite worthy to take a place beside the 
best treatises of the period. — New York Medical 
Journal, July 2, 1887. 



BABKFB, FOBDYCF, A. M., M. JD., LL. D., Fdin., 

Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, 
New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. 

Obstetrical and Clinical Essays. 12mo., about 300 pages. Preparing. 
BABBY, JOHN S., M. I)., 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. 
Extra - Uterine Pregnancy : Its Clinical History, Diagnosis, Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. 



WINCKEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. R Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 



ASHWELL'S PEACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, $3.50. 

TANNER ON PREGNANCY. Octavo, 490 pages, 
colored plates, 16 cuts. Cloth, $4.25. 



CHURCHILL ON THE PUERPERAL FEVER 
AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, $2.50. 

MEIGS ON THE NATURE, SIGNS AND TREAT- 
MENT OF CHILDBED FEVER. In one 8vo. 
volume of 346 pages. Cloth, $2.00. 



30 



Lea Brothers & Co.'s Publications — Midwfy., I>is. Childn. 



SMITH, J. LEWIS, M. D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. 

A Treatise on the Diseases of Infancy and Childhood. New (seventh) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 881 
pages, with 51 illustrations. Cloth, $4.50 ; leather, $5.50. Just ready. 
PREFACE TO THE SEVENTH EDITION. 

Since the issue of the Sixth Edition of this treatise in 1886, so many additional facts- 
have come to light relating to the etiology, nature, and treatment of the diseases of chil- 
dren that the necessary revision has produced virtually a new book. In the amount of 
information presented, the work may properly be considered to have doubled in size, but 
this real growth has been accommodatei without rendering the volume inconveniently 
large. The author has been careful in rewriting to exclude all obsolete material, and to 
condense the text to the limits of clearness. Among the diseases treated of in this and 
not in the former editions we may mention Conjunctivitis, Icterus, Sepsis, Umbilical Dis- 
eases, Hsematemesis, Melsena, Sclerema, (Edema and Pemphigus of the new-born ; 
Epilepsy, Tetany, Appendicitis, Typhlitis, and Perityphlitis. The paper on Intubation., 
by Dr. Joseph O'Dwyer, will be found interesting and instructive to those who perform 
this operation, as well as to those who wish to learn how to do it. In order to make the 
book in the highest degree useful to the practitioner, prevalent and fatal diseases have 
been described at considerable length, and special attention has been bestowed upon the 
treatment. Modes of treatment employed by physicians of world-wide reputation are in 
many instances related, and cases are detailed showing the effects of remedies. Recent 
investigations and discoveries relating to the bacterial origin of the local as well as con- 
stitutional diseases of early life have necessitated many changes in the text, and it is 
believed that all the important facts relating to the diseases treated of, brought to light by 
recent researches, are set forth in the proper chapters. 

LEISHMAN, WILLIAM, M. JD., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and 
handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, $5.50. 



The author is broad in his teachings, and dis- 
cusses briefly the comparative anatomy of the pel- 
vis and the mobility of the pelvic articulations. 
The second chapter is devoted especially to 
the study of the pelvis, while in the third the 
female organs of generation are introduced. 
The structure and development of the ovum are 
admirably described. Then follow chapters upon 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the work are 
plain and pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 

To the American student the work before us 



must prove admirably adapted. Complete in all its 

Sarts, essentially modern in its teachings, and with 
emonstrations noted for clearness and precision,, 
it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 
popular and is cordially recommended. — N. O: 
Med. and Surg. Journ., March, 1880. 

It has been well and carefully written. The 
views of the author are broad and liberal, and in- 
dicate a well-balanced judgment and matured 1 
mind. We observe no spirit of dogmatism, but 
the earnest teaching of the thoughtful observer 
and lover of true science. Take the volume as a 
whole, and it has few equals.— Maryland Medical 
Journal, Feb. 1880. 



LANDIS, HENRY G., A. M., M. L>., 

Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. 

The Management of Labor, and of the Lying-in Period. In one 

handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. 

tempt any one who should happen to commence 
the book to read it through. The author pre- 



The author has designed to place in the hands 
of the young practitioner a book in which he can 
find necessary information in an instant. As far 
as we can see, nothing is omitted. The advice is 
sound, and the proceedures are safe and practical. 
Centralblatt fur Qynakologie, December 4, 1886. 

This is a book we can heartily recommend. 
the author goes much more practically into the 
details of the management of labor than most 
textrbooks, and is so readable throughout as to 



supposes a theoretical knowledge of obstetrics,, 
and has consistently excluded from this little 
work everything that is not of practical use in the 
lying-in room. We think that if it is as widely 
read as it deserves, it will do much to improve 
obstetric practice in general. — New Orleans Medi- 
cal and Surgical Journal, Mar. 1886. 



OWEN, EDMUND, M. B., F. M. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. In one 12mo. volume of 525 pages, with 4 
chromo-lithographic plates and 85 woodcuts. Cloth, $2. See Series of Clinical Manuals,. 
page 31. 

One is immediately struck on reading this book honestly recommended to both students and 

with its agreeable style and the evidence it every- practitioners. It is full of sound information,, 

where presents of the practical familiarity of its pleasantly given.— Annals of Surgery, May, 1886. 
author with his subject. The book may be 



CONDIE'S PRACTICAL TREATISE ON THE I WEST ON SOME DISORDERS OF THE NERV- 
DISEASES OF CHILDREN. Sixth edition, re- | OUS SYSTEM IN CHILDHOOD. In one small 
vised and augmented. In one octavo volume of 12mo. volume of 127 pages. Cloth, $1.00. 
779 pages. Cloth, $5.25 ; leather, $6.25. 



Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 31 
TIDY, CHARLES MEYMOTT, M. B., F. C. 8., 

Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. 

Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00; leather, $7.00. 



The satisfaction expressed with the first portion 
of this work is in no wise lessened by a perusal of 
the second volume. We find it characterized by 
the same fulness of detail and clearness of ex- 
pression which we had occasion so highly to com- 
mend in our former notice, and which render it so 
valuable to the medical jurist. The copious 



tables of cases appended to each division of the 
subject must have cost the author a prodigious 
amount of labor and research, but they constitute 
one of the most valuable features of the book, 
especially for reference in medico-legal trials.— 
American Journal of the Medical Sciences, April, 1884. 



TAYLOB, ALFBEJD 8., M. JD., 

Lecturer on Medical Jurisprudence and Chemistry in Ouy^s Hospital, London. 

Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

By the Same Author. 
A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by John J. Eeese, M. D. In one 
large octavo volume. 

FEFFEB, AUGUSTUS J., M. 8., M. B., F. B. C. 8., 

Examiner in Forensic Medicine at the University of London. 
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students' 
Series of Manuals, below. 

STUDENTS 9 SEBIES OF MANUALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Treves' Manual of Sur- 
gery, by various writers, in Ihree volumes, each, $2; Bell's Comparative Physio ogy and Anatomv, $2; 
Gould's Surgical Diagnosis. 82; Robertson's Physiological Physics, $2; Bruce's Materia Medicaand Thera- 
peutics (4th edition), $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's 
Ditsectors' Manual, $1.50; Ralfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; 
Pepper's Surgical Pathology, $2 ; arid Klein's Elements of Histology (4th edition), $1.75. The following 
is in press : Pepper's Forensic Medicine. For separate notices see index on last page. 



SEBIES OF CLINICAL MANUALS. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and wood- 
cuts. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Broadbent on 
the Pulse, $1.75; Carter* Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25 ; Ball on 
the Rectum and Anus, $2.25 ; Marsh on the Joints, $2 ; Owen on Surgical Diseases of Children, $2 ; 
Morris on Surgical Diseases of the Kidney, $2.25 ; Pick on Fractures and Dislocations, $2 ; Butlin on 
the Tonque, $3.50; Treves on Intestinal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. 
The following is in active preparation: Lucas on Diseases of the Urethra. For separate notices see 
index on last page. 

LEA, HENBY C. 

Chapters from the Religious History of Spain.— Censorship of the 
Press. — Mystics and Illuminati. — The Endemoniadas of Queretaro. — 
El Santo Nino de la Guardia.— Brianda de Bardaxi. In one 12mo. volume 
of 522 pages. Cloth, $2.50. Just ready. 

In making researches for a History of the Spanish Inquisition the author has been 
led to investigate various subjects deserving of treatment more elaborate than could be 
accorded to them in a continuous narrative. These he has worked out in the present vol- 
ume in the hope that beside the intrinsic interest of the themes themselves, they may 
serve to explain some of the causes which reduced to impotence a nation that in the 
sixteenth, century aspired to universal monarchy. 

By the same Author. 
Superstition and Force : Essays on The Wager of Law, The "Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 
handsome royal 12mo. volume of 552 pages. Cloth, $2.50. 

By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy — Excommunication. New edition. In one very handsome royal 
octavo volume of 605 pages. Cloth, $2.50. 



Allen's Anatomy .... 

American Journal of the Medical Sciences 

American Systems of Gynecology and Obstetrics 

American System, of Practical Medicine . 

American System of Dentistry 

A shhur st' s Surgery .... 

Ash well on Diseases of Women 

Attfield's Chemistry 

Ball on the Rectum and Anus 

Barker's Obstetrical and Clinical Essays, 

Barlow's Practice of Medicine 

Barnes' System of Obstetric Medicine 

Bartholow on Electricity . . . 

Basham on Renal Diseases . 

Bell's Comparative Physiology and Anatomy 

Bellamy's Surgical Anatomy 

Berry on the Eye .... 

Billings' National Medical Dictionary . 

Blandford on Insanity 

Bloxam's Chemistry .... 

Bristowe's Practice of Medicine 

Broadbent on the Pulse 

Browne on the Throat, Nose and Ear 

Bruce's Materia Medica and Therapeutics 

Brunton's Materia Medica and Therapeutics 

Bryant's Practice of Surgery . 

Bumstead and Taylor on "Venereal. See Taylor. 

Burnett on the Ear 

Butlin on the Tongue . 

Carpenter on the Use and Abuse of Alcohol 

Carpenter's Human Physiology 

Carter & Frost's Ophthalmic Surgery 

Chambers on Diet and Regimen 

Chapman's Human Physiology 

Charles' Physiological and Pathological Chem 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector . . . 

Clouston on Insanity . 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen on the Throat .... 

Coleman's Dental Surgery 

Condie on Diseases of Children 

Cornil on Syphilis .... 

Dalton on the Circulation . , . 

Dalton's HumanPhysiology 

Davenport on Diseases of Women . 

Davis' Clinical Lectures 

Draper's Medical Physics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

Dungllson's Medical Dictionary 

Edes' Materia Medica and Therapeutics 

Edis on Diseases of Women . 

Ellis' Demonstrations of Anatomy 

Emmet'3 Gynaecology 

Erichsen's System of Surgery 

Farquharson's Therapeutics and Mat. Med. 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percussion 

Flint on Phthisis .... 

Flint on Respiratory Organs 

Flint on the Heart .... 

Flint's Essays ..... 

Flint's Practice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology .... 

Fothergill's Handbook of Treatment 

Fownes' Elementary Chemistry . 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages . 

Gant's Student's Surgery 

Gibney's Orthopaedic Surgery 

Gould's Surgical Diagnosis . 

Gray's Anatomy ..... 

Gray on Nervous Diseases 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

Gross System of Surgery 

Habershon on the Abdomen 

Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hare's Practical Therapeutics 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Hermann's Experimental Pharmacology 

Hill on Syphilis . . . . . 

Hillier's Handbook of Skin Diseases 

Hoblyn's Medical Dictionary 

Hodge on Women 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

Holmes' Principles and Practice of Surgery 

Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever 

Hutchinson on Syphilis 

Hyde on the Diseases of the Skin . 

Jones (C. Handheld) on Nervous Disorders 



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25 
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Juler's Ophthalmic Science and Practice 
King's Manual of Obstetrics . 

Klein's Histology 13,32 

Landis on Labor . 

La Roche on Pneumonia, Malaria, etc. . . IT 

La Roche on Yellow Fever . . . . 1& 

Laurence and Moon's Ophthalmic Surgery • 22 
Lawson on the Eye, Orbit and Evelid . . 22: 

Lea's Chapters from Religious History of Spain 31 
Lea's Studies in Church History ... 31 
Lea's Superstition and Force ... 31 

Lee on Syphilis . 25> 

Lehmann f s Chemical Physiology . 
Leishman's Midwifery .... 30 

Lucas on Diseases of the Urethra . I . .24,31* 

Ludlow's Manual of Examinations 

Lyons on Fe\er . . . . . .1© 

Maisch's Organic Materia Medica . „ . 11 

Marsh on the Joints . . .21,31 

May on Diseases of Women . . . .28 

Medical News . ... 1 

Medical News Visiting List .... 3. 

Medical News Physicians' Ledger . 

Meigs on Childbed Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery . . .21 

Mitchell's Nervous Diseases of Women . . 19 

Morris on Diseases of the Kidney . . . 24, 3i 

National Dispensatory . . . .12 

National Medical Dictionary 

Neill and Smith's Compendium of Med. Sci. 

Nettleship on Diseases of the Eye . 

Norris and Oliver on the Eye 

Owen on Diseases of Children 

Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery . 

Pavy on Digestion and its Disorders . . 17 

Payne's General Pathology . 

Pepper's System of Medicine . . a5 

Pepper's Forensic Medicine . . . .31 

Pepper's Surgical Pathology . . . 13,31k 

Pick on Fractures and Dislocations . . 22, 31 

Pirrie's System of Surgery . ... 21 

Playfair on Nerve Prostration and Hysteria . 19 
Playfair's Midwifery .... 

Politzer on the Ear and its Diseases 
Power's Human Physiology . 

Purdy on Bright's Disease and Allied A Sections 24 

Ralfe's Clinical Chemistry . . .10, 3fi 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Compend of Anatomy . 

Roberts' Surgery .... 

Robertson's Physiological Physics 

Ross on Nervous Diseases 

Savage on Insanity, including Hysteria . 

Schafer's Essentials of Histology, 

Schreiber on Massage . 

Seiler on the Throat. Nose and Naso-Pharynx 

Senn's Surgical Bacteriology 

Series of Clinical Manuals .... 

Simon's Manual of Chemistry 

Slade on Diphtheria . . . . t 

Smith (Edward) on Consumption . 

Smith (J. Lewis) on Children 

Smith's Operative Surgery 

Stille on Cholera ..... 

StillS & Maisch's National Dispensatory 

Still6's Therapeutics and Materia Medica 

Stimson on Fractures and Dislocations 

Stimson's Operative Surgery 

Students' Series of Manuals .... 

Sturges' Clinical Medicine .... 

Tait's Diseases of Women and Abdom. Surgery 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor's Atlas of Venereal and Skin Diseases 

Taylor on Venereal Diseases 

Taylor on Poisons ..... 

Taylor's Medical Jurisprudence 

Thomas on Diseases of Women 

Thompson on Stricture . 

Thompson on Urinary Organs 

Tidy's Legal Medicine . . . 

Todd on Acute Diseases 

Treves' Manual of Surgery .... 

Treves' Surgical Applied Anatomy 

Treves on Intestinal Obstruction . 

Tuke on the Influence of Mind on the Body 

Vaughan & Novy's Ptomaines and Leucornamea 

Visiting List, The Medical News . 

Walshe on the Heart ..... 

Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Williams on Consumption . .. 

Wilson's Handbook of Cutaneous Medicine . 26 

Wilson's Human Anatomy . . ,■•_,. : _£ 

Winckel on Pathol, and Treatment of Childbed 29* 

Wohler's Organic Chemistry f 

Woodhead's Practical Pathology . . • 13 

Year-Books of Treatment for 1886, '87, '89 and '90 1? 

Yeo on Food in Health and Disease . .17,33 



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LEA BROTHERS & CO., Philadelphia. 



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